Guided Notes

Clinical Terminologies & Code Systems

SNOMED CT, LOINC, RxNorm, ICD-10-CM, CPT, NDC, CVX and UCUM — what each one codes, where it lives in the EHR, and why mapping matters.

Why standard codes?

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Computers can't reliably compare free text: 'heart attack', 'MI' and 'myocardial infarction' are the same thing. Standard code systems give each concept a unique code so that: • decision support can recognize conditions and drugs, • quality measures and research can count reliably, • data can be exchanged between different EHRs, • billing uses the required code sets.

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