2011 08 15 - 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 4912 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 as 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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Reprinted from Merrill’s Atlas of Radiographic Positions and Radiologic Procedures, 9th edition, Ballinger and Frank, page 548 (figure 10-68), copyright 1999 Mosby, with permission from Elsevier Science.


http://www.us.elsevierhealth.com/product.jsp?isbn=0323016049

http://www.us.elsevierhealth.com/product.jsp?isbn=0323016049

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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• Study Observation

Coordination with other Standards SNOMED CT RadLex DICOM

Additional development: Interventional Radiology Combination of Modalities (e.g., PET/CT) Surgical Component of Imaging Therapeutic services


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Radiology Discussion - Issues

Additional views Injection for Multiple, non-adjacent anatomical sites Multiple, non-compatible contrast media Multiple modalities, or no modality at all Including reason for exam Not specific to radiology (surgical procedure) Panels


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Questions?


2011 08 15 - Clinical LOINC Tutorial - Imaging

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