Representing Clinical Tests Ordered/Performed

Type	Standard / Implementation Specification	Standards Process Maturity	Implementation Maturity	Adoption Level	Federally required	Cost	Test Tool Availability
Standard	LOINC®	Final	Production	Feedback Requested	No	Free
Standard	CPT®	Final	Production	Feedback Requested	No	$	N/A

Limitations, Dependencies, and Preconditions for Consideration	Applicable Value Set(s) and Starter Set(s)
Clinical Tests is a USCDI data class representing non-imaging and non-laboratory tests performed on a patient that results in structured or unstructured (narrative) findings specific to the patient, such as electrocardiogram (ECG), visual acuity exam, macular exam, or graded exercise testing (GXT), to facilitate the diagnosis and management of conditions.	USCDI Clinical Tests Minimum Set This value set represents a sampling of several specialty specific tests including cardiology and ophthalmology, and is not the entire universe of possible clinical test codes that may be needed for these or other specialties. Current Procedural Terminology (CPT)

Comment

Submitted by mattreid on 2022-09-26

Comment for Representing Non-imaging and Non-laboratory Clinical

Comment for Representing Non-imaging and Non-laboratory Clinical Tests

The American Medical Association requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Non-imaging and Non-laboratory Clinical Tests. The CPT code set contains numerous codes for non-imaging and non-laboratory clinical tests, including, but not limited to:

Electroencephalography (EEG)
Echocardiography (EKG)
Cardiovascular and exercise stress tests
Pulmonary function tests
Electromyography (EMG)
Electroretinography (ERG)
Audiologic function tests
Evoked potential tests
Intraocular pressure measurement
Visual acuity and function tests
Allergy challenge tests
Fetal monitoring
Sleep studies

CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, laboratory, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.