2009 08 13 - Clinical LOINC Tutorial - Imaging

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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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QUESTIONS?