§ 170.207 - Vocabulary standards for representing electronic health information.

§ 170.207 Vocabulary standards for representing electronic health information.

Cross Reference

Link to an amendment published at 89 FR 1426, Jan. 9, 2024.

Cross Reference

The

effective date of this amendment was corrected to read Mar. 11, 2024, at 89 FR 8548, Feb. 8, 2024.

The Secretary adopts the following code sets, terminology, and nomenclature as the vocabulary standards for the purpose of representing electronic health information:

(a) Problems.

(1) [Reserved]

(2) [Reserved]

(3)

Standard.

IHTSDO

SNOMED CT®

International Release July 2012 (incorporated by reference in § 170.299) and US Extension to SNOMED CT® March 2012

, U.S. Edition, March 2022 Release (incorporated by reference

in

, see § 170.299).

(2)–(3) [Reserved]

(4) Standard. IHTSDO SNOMED CT®, U.S. Edition, September 2015 Release (incorporated by reference in § 170.299).

(b) Procedures.

(1) [Reserved]

(2) Standard. The code set specified at 45 CFR 162.1002(a)(5).

(3) Standard. The code set specified at 45 CFR 162.1002(a)(4).

(4) Standard. The code set specified at 45 CFR 162.1002(c)(3) for the indicated procedures or other actions taken.

(c) Laboratory tests.

(1) [Reserved]

(2)

Standard. Logical Observation Identifiers Names and Codes (LOINC®) Database

version

Version 2.

40

72, a universal code system for identifying

laboratory and clinical observations

health measurements, observations, and documents produced by the Regenstrief Institute, Inc., February 16, 2022 (incorporated by reference

in

, see § 170.299).

(2) [Reserved]

(3) Standard. Logical Observation Identifiers Names and Codes (LOINC®) Database version 2.52, a universal code system for identifying laboratory and clinical observations produced by the Regenstrief Institute, Inc. (incorporated by reference in § 170.299).

(d) Medications.

(1)–( Standard. RxNorm, a standardized nomenclature for clinical drugs produced by the United States National Library of Medicine, July 5, 2022 (incorporated by reference, see § 170.299).

(2) [Reserved]

(3) Standard. RxNorm, a standardized nomenclature for clinical drugs produced by the United States National Library of Medicine, September 8, 2015 Release (incorporated by reference in § 170.299).

(4) Standard. The code set specified at 45 CFR 162.1002(b)(2) as referenced in 45 CFR 162.1002(c)(1) for the time period on or after October 1, 2015.

(e) Immunizations.

(1)–(2) [Reserved]

(

Standard. HL7® Standard Code Set CVX—Vaccines Administered, dated through June 15, 2022 (incorporated by reference, see § 170.299).

(2) Standard. National Drug Code Directory (NDC)—Vaccine NDC Linker, dated July 19, 2022 (incorporated by reference, see § 170.299).

(3) Standard. HL7 Standard Code Set CVX—Vaccines Administered, updates through August 17, 2015 (incorporated by reference in § 170.299).

(4) Standard. National Drug Code Directory (NDC)—Vaccine NDC Linker, updates through August 17, 2015 (incorporated by reference in § 170.299).

(f) Race and Ethnicity —

(1) Standard. The Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, Statistical Policy Directive No. 15, as revised, October 30, 1997 (incorporated by reference in § 170.299).

(2) Standard. CDC Race and Ethnicity Code Set Version 1.0 (March 2000) (incorporated by reference in § 170.299).

(3) Standard. CDC Race and Ethnicity Code Set Version 1.2 (July 08, 2021) (incorporated by reference, see § 170.299).

(g) Preferred language.

(1) [Reserved]

(2) Standard. Request for Comments (RFC) 5646 (incorporated by reference in § 170.299).

(h) [Reserved]

(i) Encounter diagnoses. Standard. The code set specified at 45 CFR 162.1002(c)(2) for the indicated conditions.

(j)–(l) [Reserved]

(m) Numerical references —

(1) Standard. The Unified Code of Units of Measure, Revision 1.9 (incorporated by reference in § 170.299).

(2) [Reserved]

(

Standard. The Unified Code for Units of Measure, Version 2.1, November 21, 2017 (incorporated by reference, see § 170.299).

(n) Sex —

(1) Standard. Birth sex must be coded in accordance with HL7 HL7® Version 3 Standard, Value Sets for AdministrativeGender and NullFlavor (incorporated by reference in , see § 170.299), up until the adoption of this standard expires January 1, 2026, attributed as follows:

(i) Male. M;

(ii) Female. F;

(iii) Unknown. nullFlavor NullFlavor UNK.

(2) [Reserved]

(

Standard. Sex must be coded in accordance with, at a minimum, the version of SNOMED CT ® U.S. Edition codes specified in paragraph (a)(1) of this section.

(3) Standard. Sex Parameter for Clinical Use must be coded in accordance with, at a minimum, the version of LOINC® codes specified in paragraph (c)(1) of this section.

(o) Sexual orientation and gender identityinformation —

(1) Standard. Sexual orientation must be coded in accordance with, at a minimum, the version of SNOMED CT ® SNOMED–CT® U.S. Edition codes specified in paragraph (a)(4) of this section for paragraphs (o)(1)(i) through (iii) of this section and HL7 Version 3 Standard, Value Sets for AdministrativeGender and NullFlavor (incorporated by reference in , see § 170.299), up until the adoption of this standard expires on January 1, 2026, for paragraphs (o)(1)(iv) through (vi) of this section, attributed as follows:

(i) Lesbian, gay or homosexual. 38628009

(ii) Straight or heterosexual. 20430005

(iii) Bisexual. 42035005

(iv) Something else, please describe. nullFlavor NullFlavor OTH

(v) Don't know. nullFlavor NullFlavor UNK

(vi) Choose not to disclose. nullFlavor NullFlavor ASKU

(2) Standard. Gender identity must be coded in accordance with, at a minimum, the version of SNOMED CT ® SNOMED–CT® codes specified in paragraph (a)(4) of this section for paragraphs (o)(2)(i) through (v) of this section and HL7 HL7® Version 3 Standard, Value Sets for AdministrativeGender and NullFlavor (incorporated by reference in § 170.299), up until the adoption of this standard expires January 1, 2026, for paragraphs (o)(2)(vi) and (vii) of this section, attributed as follows:

(i) Male. 446151000124109

(ii) Female. 446141000124107

(iii) Female-to-Male (FTM)/Transgender Male/Trans Man. 407377005

(iv) Male-to-Female (MTF)/Transgender Female/Trans Woman. 407376001

(v) Genderqueer, neither exclusively male nor female. 446131000124102

(vi) Additional gender category or other, please specify. nullFlavor NullFlavor OTH

(vii) Choose not to disclose. nullFlavor ASKU

(

NullFlavor ASKU

(3) Standard. Sexual Orientation and Gender Identity must be coded in accordance with, at a minimum, the version of SNOMED CT® codes specified in paragraph (a)(1) of this section.

(4) Standard. Pronouns must be coded in accordance with, at a minimum, the version of LOINC® codes specified in paragraph (c)(1) of this section.

(p) Social, psychological, and behavioral data —

(1) Financial resource strain. Financial resource strain must be coded in accordance with, at a minimum, the version of LOINC ® LOINC® codes specified in paragraph (c)(31) of this section and attributed with the LOINC ® LOINC® code 76513–1 and LOINC ® LOINC® answer list ID LL3266–5.

(2) Education. Education must be coded in accordance with, at a minimum, the version of LOINC® codes specified in paragraph (c)(31) of this section and attributed with LOINC® code 63504–5 and LOINC® answer list ID LL1069–5.

(3) Stress. Stress must be coded in accordance with, at a minimum, the version of LOINC® codes specified in paragraph (c)(31) of this section and attributed with the LOINC® code 76542–0 and LOINC® answer list LL3267–3.

(4) Depression. Depression must be coded in accordance with, at a minimum, the version of LOINC® codes specified in paragraph (c)(31) of this section and attributed with LOINC® codes 55757–9, 44250–9 (with LOINC® answer list ID LL358–3LL361–7), 44255–8 (with LOINC® answer list ID LL358–3LL361–7), and 55758–7 (with the answer coded with the associated applicable unit of measure in the standard specified in § 170.207paragraph (m)(12) of this section).

(5) Physical activity. Physical activity must be coded in accordance with, at a minimum, the version of LOINC® codes specified in paragraph (c)(31) of this section and attributed with LOINC® codes 68515–6 and 68516–4. The answers must be coded with the associated applicable unit of measure in the standard specified in § 170.207paragraph (m)(12) of this section.

(6) Alcohol use. Alcohol use must be coded in accordance with, at a minimum, the version of LOINC® codes specified in paragraph (c)(31) of this section and attributed with LOINC® codes 72109–2, 68518–0 (with LOINC® answer list ID LL2179–1), 68519–8 (with LOINC® answer list ID LL2180–9), 68520–6 (with LOINC® answer list ID LL2181–7), and 75626–2 (with the answer coded with the associated applicable unit of measure in the standard specified in paragraph (m)(2) of this section).

(7) Social connection and isolation. Social connection and isolation must be coded in accordance with, at a minimum, the version of LOINC® codes specified in paragraph (c)(31) of this section and attributed with the LOINC® codes 76506–5, 63503–7 (with LOINC LOINC® answer list ID LL1068–7), 76508–1 (with the associated applicable unit of measure in the standard specified in § 170.207paragraph (m)(12) of this section), 76509–9 (with the associated applicable unit of measure in the standard specified in § 170.207paragraph (m)(12) of this section), 76510–7 (with the associated applicable unit of measure in the standard specified in § 170.207paragraph (m)(12) of this section), 76511–5 (with LOINC answer list ID LL963–0), and 76512–3 (with the associated applicable unit of measure in the standard specified in § 170.207paragraph (m)(12) of this section).

(8) Exposure to violence (intimate partner violence). Exposure to violence: Intimate partner violence must be coded in accordance with, at a minimum, the version of LOINC® codes specified in paragraph (c)(31) of this section and attributed with the LOINC® code 76499–3, 76500–8 (with LOINC® answer list ID LL963–0), 76501–6 (with LOINC® answer list ID LL963–0), 76502–4 (with LOINC® answer list ID LL963–0), 76503–2 (with LOINC® answer list ID LL963–0), and 76504–0 (with the associated applicable unit of measure in the standard specified in § 170.207paragraph (m)(12) of this section).

(q) Patient matching —

(1) Phone number standard. ITU–T E.123, Series E: Overall Network Operation, Telephone Service, Service Operation and Human Factors, International operation—General provisions concerning users: Notation for national and international telephone numbers, email addresses and web addresses (incorporated by reference in § 170.299); and ITU–T E.164, Series E: Overall Network Operation, Telephone Service, Service Operation and Human Factors, International operation—Numbering plan of the international telephone service: The international public telecommunication numbering plan (incorporated by reference in § 170.299).

(2) [Reserved]

(r) Provider type —

(1) Standard. Crosswalk: Medicare Provider/Supplier to Healthcare Provider Taxonomy, April 2, 2015 (incorporated by reference in § 170.299).

(2) [Reserved]

(

Standard. Medicare Provider and Supplier Taxonomy Crosswalk, 2021 (incorporated by reference, see § 170.299).

(s) Patient insurance —

(1) Standard. Public Health Data Standards Consortium Source of Payment Typology Code Set Version 5.0 (October 2011) (incorporated by reference in § 170.299).

(2) [Reserved]

[

Standard. Public Health Data Standards Consortium Users Guide for Source of Payment Typology, Version 9.2 (incorporated by reference, see § 170.299).

[75 FR 44649, July 28, 2010, as amended at 77 FR 54284, Sept. 4, 2012; 79 FR 54478, Sept. 11, 2014; 80 FR 62744, Oct. 16, 2015; 80 FR 76871, Dec. 11, 2015; 85 FR 25940, May 1, 2020; 89 FR 1426, Jan. 9, 2024]