LOINC® Tutorial: Imaging Names and Codes Pat Wilson, RT(R), CPC, PMP – 3M TCS/HDD Team

Overview Developed as header information for the narrative of a diagnostic imaging study Clinical LOINC® terms are indicated by Class and Class Type Imaging terms are Class Type 2 Class is primarily RAD, with some overlap in other classes such as OB.US

Developed as header information for the narrative of a diagnostic imaging study

Clinical LOINC® terms are indicated by Class and Class Type

Imaging terms are Class Type 2

Class is primarily RAD, with some overlap in other classes such as OB.US

Example of Class Other Than Rad Class - OB.US Code - 12029-5 Study observation:Find:Pt:Abdomen^fetus:Nar:US Class – Card.US Code - 18141-2 Study observation:Find:Pt:Cardiovascular.central: Nar:US

Class - OB.US

Code - 12029-5

Study observation:Find:Pt:Abdomen^fetus:Nar:US

Class – Card.US

Code - 18141-2

Study observation:Find:Pt:Cardiovascular.central: Nar:US

Radiology Terms Approximately 4800 Radiology specific terms Contributions from Indiana University, Intermountain, Partners and the DoD through 3M Terms are imaging findings and measurements Majority of terms are indicated a both observation and orderable

Approximately 4800 Radiology specific terms

Contributions from Indiana University, Intermountain, Partners and the DoD through 3M

Terms are imaging findings and measurements

Majority of terms are indicated a both observation and orderable

Examples of Orderable Versus Observation Observation Code - 38261-4 Bone density:MAric:Pt:Hip:Qn:XR.DEXA Orderable and Observation Code - 26074-5 Views^W contrast intraarticular:Find:Pt:Knee.left:Nar:XR.fluor

Observation

Code - 38261-4

Bone density:MAric:Pt:Hip:Qn:XR.DEXA

Orderable and Observation

Code - 26074-5

Views^W contrast intraarticular:Find:Pt:Knee.left:Nar:XR.fluor

LOINC ® Six Axes for Imaging Component: views, multisection, prone, ejection fraction, thickness, density, long axis Property: finding, impression, length, mass area, volume rate, percentile Timing: point in time, study, 15 minutes, 1 hour System: heart, ^patient,elbow.left,^fetus, liver, aorta.thoracic Scale: narrative, quantitative Method: ultrasound.measured, CT.3D, fluoroscopy

Component: views, multisection, prone, ejection fraction, thickness, density, long axis

Property: finding, impression, length, mass area, volume rate, percentile

Timing: point in time, study, 15 minutes, 1 hour

System: heart, ^patient,elbow.left,^fetus, liver, aorta.thoracic

Scale: narrative, quantitative

Method: ultrasound.measured, CT.3D, fluoroscopy

Component – View versus Film Code - 37690-51 Views 2:Find:Pt:Femur.right:Nar:XR Code - 37692-1 Views AP & lateral:Find:Pt:Femur.right:Nar:XR Code - 42273-3 Views 6:Find:Pt:Ankle.bilateral:Nar:XR Code - 42699-9 View 1:Find:Pt:Abdomen+Chest:Nar:XR

Code - 37690-51

Views 2:Find:Pt:Femur.right:Nar:XR

Code - 37692-1

Views AP & lateral:Find:Pt:Femur.right:Nar:XR

Code - 42273-3

Views 6:Find:Pt:Ankle.bilateral:Nar:XR

Code - 42699-9

View 1:Find:Pt:Abdomen+Chest:Nar:XR

Component – Position versus Patient Orientation Code - 24637-1 View AP L-lateral-decubitus:Find:Pt:Chest:Nar:XR Code - 24639-7 View L-lateral upright:Find:Pt:Chest:Nar:XR Code - 37033-8 View transthoracic:Find:Pt:Humerus.left:Nar:XR

Code - 24637-1

View AP L-lateral-decubitus:Find:Pt:Chest:Nar:XR

Code - 24639-7

View L-lateral upright:Find:Pt:Chest:Nar:XR

Code - 37033-8

View transthoracic:Find:Pt:Humerus.left:Nar:XR

Component – Limited versus Complete Code - 46347-1 Views GE 3:Find:Pt:Ankle.right:Nar:XR Code - 36089-1 Multisection limited:Find:Pt:Chest:Nar:CT Code - 43470-4 Views LE 3:Find:Pt:Skull:Nar:XR

Code - 46347-1

Views GE 3:Find:Pt:Ankle.right:Nar:XR

Code - 36089-1

Multisection limited:Find:Pt:Chest:Nar:CT

Code - 43470-4

Views LE 3:Find:Pt:Skull:Nar:XR

Component – Guidance Code – 35900-0 Guidance for biopsy:Find:Pt:Liver:Nar:XR.fluor Code - 24623-1 Guidance for anesthetic block injection:Find:Pt:Celiac plexus:Nar:CT Code - 44169-1 Guidance for abscess drainage:Find:Pt:Peritoneal space:Nar:US

Code – 35900-0

Guidance for biopsy:Find:Pt:Liver:Nar:XR.fluor

Code - 24623-1

Guidance for anesthetic block injection:Find:Pt:Celiac plexus:Nar:CT

Code - 44169-1

Guidance for abscess drainage:Find:Pt:Peritoneal space:Nar:US

Component – Eponyms Code - 37164-1 Views lateral & Caldwell & Waters:Find:Pt:Facial bones:Nar:XR Code - 37035-3 View Grashey:Find:Pt:Shoulder.bilateral:Nar:XR Code - 37625-1 View Ferguson:Find:Pt:Pelvis:Nar:XR

Code - 37164-1

Views lateral & Caldwell & Waters:Find:Pt:Facial bones:Nar:XR

Code - 37035-3

View Grashey:Find:Pt:Shoulder.bilateral:Nar:XR

Code - 37625-1

View Ferguson:Find:Pt:Pelvis:Nar:XR

Component - Challenges Code - 39410-6 View AP^W L-bending:Find:Pt:Spine.thoracic:Nar:XR Code - 37486-8 Views Broden^W manual stress:Find:Pt:Ankle:Nar:XR Code - 37579-0 Views^W & WO weight:Find:Pt:Acromioclavicular joint:Nar:XR

Code - 39410-6

View AP^W L-bending:Find:Pt:Spine.thoracic:Nar:XR

Code - 37486-8

Views Broden^W manual stress:Find:Pt:Ankle:Nar:XR

Code - 37579-0

Views^W & WO weight:Find:Pt:Acromioclavicular joint:Nar:XR

Component - Subparts Code - 44108-9 Guidance for aspiration.fine needle:Find:Pt:Adrenal gland:Nar:CT Code - 30711-6 Multisection^manipulation.infant view:Find:Pt:Hip:Nar:US Code - 24632-2 Views AP portable:Find:Pt:Chest:Nar:XR

Code - 44108-9

Guidance for aspiration.fine needle:Find:Pt:Adrenal gland:Nar:CT

Code - 30711-6

Multisection^manipulation.infant view:Find:Pt:Hip:Nar:US

Code - 24632-2

Views AP portable:Find:Pt:Chest:Nar:XR

System – Multiple Organs or Locations Code - 24700-7 Views for leg length:Find:Pt:Femur+Tibia:Nar:XR Code - 24819-5 Views^W Tc-99m calcium colloid IV: Find: Pt: Liver+Spleen:Nar:Radnuc Code - 30861-9 Multisection:Find:Pt:Aortic arch+Neck vessels: Nar:MRI.angio

Code - 24700-7

Views for leg length:Find:Pt:Femur+Tibia:Nar:XR

Code - 24819-5

Views^W Tc-99m calcium colloid IV: Find: Pt: Liver+Spleen:Nar:Radnuc

Code - 30861-9

Multisection:Find:Pt:Aortic arch+Neck vessels: Nar:MRI.angio

System - Laterality Code - 26175-0 Views screening:Find:Pt:Breast.bilateral:Nar:Mam Code - 26347-5 Views diagnostic:Find:Pt:Breast.left:Nar:Mam Code - 24605-8 Views diagnostic:Find:Pt:Breast:Nar:Mam Code - 46380-2 Views:Find:Pt:Breast implant.unilateral:Nar:Mam

Code - 26175-0

Views screening:Find:Pt:Breast.bilateral:Nar:Mam

Code - 26347-5

Views diagnostic:Find:Pt:Breast.left:Nar:Mam

Code - 24605-8

Views diagnostic:Find:Pt:Breast:Nar:Mam

Code - 46380-2

Views:Find:Pt:Breast implant.unilateral:Nar:Mam

System - Subpart Code - 24747-8 Multisection^W contrast IV:Find:Pt:Head.sagittal sinus:Nar:MRI.angio Code - 36082-6 Multisection:Find:Pt:Vena cava.inferior: Nar: MRI.angio Code - 24532-4 Multisection:Find:Pt:Abdomen.RUQ:Nar:US

Code - 24747-8

Multisection^W contrast IV:Find:Pt:Head.sagittal sinus:Nar:MRI.angio

Code - 36082-6

Multisection:Find:Pt:Vena cava.inferior: Nar: MRI.angio

Code - 24532-4

Multisection:Find:Pt:Abdomen.RUQ:Nar:US

Method – Modality Subpart Code - 42174-3 Views screening:Find:Pt:Breast.bilateral:Nar:Mam.FFD Code - 36782-1 Multisection:Find:Pt:Subclavian artery:Nar:MRI.angio Code - 39432-0 Multisection:Find:Pt:Lower extremity vein.left: Nar:US.doppler

Code - 42174-3

Views screening:Find:Pt:Breast.bilateral:Nar:Mam.FFD

Code - 36782-1

Multisection:Find:Pt:Subclavian artery:Nar:MRI.angio

Code - 39432-0

Multisection:Find:Pt:Lower extremity vein.left: Nar:US.doppler

Additional Issues and Development Overlap with Document Types Coordination with other Standards SNOMED CT RadLex DICOM Additional terms need to be developed for: PET Interventional Radiology Combination of Modalities (e.g., NucMed/CT) Surgical Component of Imaging

Overlap with Document Types

Coordination with other Standards

SNOMED CT

RadLex

DICOM

Additional terms need to be developed for:

PET

Interventional Radiology

Combination of Modalities (e.g., NucMed/CT)

Surgical Component of Imaging

QUESTIONS?