Procedures

Generate realistic Procedure resources with proper coding and clinical context.

Coding Systems

Use dual coding when possible:

• CPT (Current Procedural Terminology): system = http://www.ama-assn.org/go/cpt
• SNOMED CT: system = http://snomed.info/sct
• HCPCS: system = https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
• ICD-10-PCS (inpatient): system = http://www.cms.gov/Medicare/Coding/ICD10

Common Procedures by Specialty

General Surgery:

• 47562 Laparoscopic cholecystectomy (SNOMED 45595009)
• 44970 Laparoscopic appendectomy (SNOMED 80146002)
• 49505 Inguinal hernia repair (SNOMED 44558001)

Orthopedic:

• 27447 Total knee arthroplasty (SNOMED 609588000)
• 27130 Total hip arthroplasty (SNOMED 52734007)
• 27245 ORIF femur fracture (SNOMED 179097006)
• 29881 Knee arthroscopy with meniscectomy (SNOMED 112727005)

Cardiology:

• 93458 Left heart catheterization (SNOMED 41976001)
• 92928 PCI with stent placement (SNOMED 36969009)
• 33533 CABG (SNOMED 232717009)
• 33208 Pacemaker insertion (SNOMED 307280005)

GI / Endoscopy:

• 43239 EGD with biopsy (SNOMED 386810004)
• 45380 Colonoscopy with biopsy (SNOMED 73761001)
• 47563 Lap cholecystectomy with cholangiogram (SNOMED 45595009)

Pulmonary / Critical Care:

• 31600 Tracheostomy (SNOMED 48387007)
• 94002 Mechanical ventilation initiation (SNOMED 40617009)
• 32405 Lung biopsy (SNOMED 15081005)

OB/GYN:

• 59510 Cesarean delivery (SNOMED 11466000)
• 59400 Vaginal delivery (SNOMED 177184002)
• 58661 Laparoscopic salpingectomy (SNOMED 287664005)

Urology:

• 52601 TURP (SNOMED 90199006)
• 50590 Lithotripsy (SNOMED 236990002)

Dermatology / Minor:

• 11102 Skin biopsy punch (SNOMED 240977001)
• 17000 Cryotherapy destruction (SNOMED 26782000)

Radiology (Interventional):

• 36556 Central line insertion (SNOMED 392230005)
• 75625 Aortography (SNOMED 77343006)

Emergency / Bedside:

• 36415 Venipuncture (SNOMED 82078001)
• 12001 Wound repair simple (SNOMED 225358003)
• 31500 Intubation (SNOMED 112798008)

Status

• preparation, in-progress, not-done, on-hold, stopped, completed, entered-in-error, unknown.
• For not-done: include statusReason (medical contraindication, patient refusal, etc.).

Body Site

Include Procedure.bodySite with SNOMED CT lateralized codes:

• Left knee (82169009), Right hip (62175007), Abdomen (818983003), Chest (51185008), Heart (80891009), Colon (71854001), Lung (39607008).

Outcome

Use Procedure.outcome with codes from http://snomed.info/sct:

• 385669000 Successful, 385671000 Unsuccessful, 385670004 Partially successful.

Complications

Include Procedure.complication and complicationDetail:

• Infection (SNOMED 128241005), Hemorrhage (131148009), Wound dehiscence (225553008).

Performers

• Procedure.performer[].actor → Reference(Practitioner/{id}).
• Procedure.performer[].function — primary surgeon, first assistant, anesthesiologist.

References

• Procedure.subject → Reference(Patient/{id}) — required.
• Procedure.encounter → Reference(Encounter/{id}).
• Procedure.reasonReference → Reference(Condition/{id}) — indication.
• Procedure.report → Reference(DiagnosticReport/{id}) — operative report.
• Procedure.basedOn → Reference(ServiceRequest/{id}).