45 CFR 170.207 - Vocabulary standards for representing electronic health information.

Beta! The text on the eCFR tab represents the unofficial eCFR text at ecfr.gov.
§ 170.207 Vocabulary standards for representing electronic health information.

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 Release (incorporated by reference in § 170.299).

(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 2.40, a universal code system for identifying laboratory and clinical observations produced by the Regenstrief Institute, Inc. (incorporated by reference in § 170.299).

(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) [Reserved]

(2) Standard. RxNorm, a standardized nomenclature for clinical drugs produced by the United States National Library of Medicine, August 6, 2012 Release (incorporated by reference in § 170.299).

(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).

(e) Immunizations.

(1) [Reserved]

(2) Standard. HL7 Standard Code Set CVX - Vaccines Administered, updates through July 11, 2012 (incorporated by reference in § 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).

(g) Preferred language -

(1) Standard. As specified by the Library of Congress, ISO 639-2 alpha-3 codes limited to those that also have a corresponding alpha-2 code in ISO 639-1 (incorporated by reference in § 170.299).

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

(h) Smoking status. Standard. Smoking status must be coded in one of the following SNOMED CT® codes:

(1) Current every day smoker. 449868002

(2) Current some day smoker. 428041000124106

(3) Former smoker. 8517006

(4) Never smoker. 266919005

(5) Smoker, current status unknown. 77176002

(6) Unknown if ever smoked. 266927001

(7) Heavy tobacco smoker. 428071000124103

(8) Light tobacco smoker. 428061000124105

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

(j) Family health history. HL7 Version 3 Standard: Clinical Genomics; Pedigree, (incorporated by reference in § 170.299).

(k)-(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]

(n) Sex -

(1) Standard. Birth sex must be coded in accordance with HL7 Version 3 Standard, Value Sets for AdministrativeGender and NullFlavor (incorporated by reference in § 170.299), attributed as follows:

(i) Male. M

(ii) Female. F

(iii) Unknown. nullFlavor UNK

(2) [Reserved]

(o) Sexual orientation and gender identity -

(1) Standard. Sexual orientation must be coded in accordance with, at a minimum, the version of SNOMED CT ® 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 § 170.299), 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 OTH

(v) Don't know. nullFlavor UNK

(vi) Choose not to disclose. nullFlavor ASKU

(2) Standard. Gender identity must be coded in accordance with, at a minimum, the version of SNOMED CT ® codes specified in paragraph (a)(4) of this section for paragraphs (o)(2)(i) through (v) of this section and HL7 Version 3 Standard, Value Sets for AdministrativeGender and NullFlavor (incorporated by reference in § 170.299), 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 OTH

(vii) Choose not to disclose. nullFlavor ASKU

(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 ® codes specified in paragraph (c)(3) of this section and attributed with the LOINC ® code 76513-1 and 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)(3) 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)(3) 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)(3) of this section and attributed with LOINC® codes 55757-9, 44250-9 (with LOINC® answer list ID LL358-3), 44255-8 (with LOINC® answer list ID LL358-3), and 55758-7 (with the answer coded with the associated applicable unit of measure in the standard specified in § 170.207(m)(1)).

(5) Physical activity. Physical activity must be coded in accordance with, at a minimum, the version of LOINC® codes specified in paragraph (c)(3) 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 § 170.207(m)(1).

(6) Alcohol use. Alcohol use must be coded in accordance with, at a minimum, the version of LOINC® codes specified in paragraph (c)(3) 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.

(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)(3) of this section and attributed with the LOINC® codes 76506-5, 63503-7 (with LOINC answer list ID LL1068-7), 76508-1 (with the associated applicable unit of measure in the standard specified in § 170.207(m)(1)), 76509-9 (with the associated applicable unit of measure in the standard specified in § 170.207(m)(1)), 76510-7 (with the associated applicable unit of measure in the standard specified in § 170.207(m)(1)), 76511-5 (with LOINC answer list ID LL963-0), and 76512-3 (with the associated applicable unit of measure in the standard specified in § 170.207(m)(1)).

(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)(3) 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 § 170.207(m)(1)).

(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]

(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]

[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]

This is a list of United States Code sections, Statutes at Large, Public Laws, and Presidential Documents, which provide rulemaking authority for this CFR Part.

This list is taken from the Parallel Table of Authorities and Rules provided by GPO [Government Printing Office].

It is not guaranteed to be accurate or up-to-date, though we do refresh the database weekly. More limitations on accuracy are described at the GPO site.


United States Code
U.S. Code: Title 5 - GOVERNMENT ORGANIZATION AND EMPLOYEES
U.S. Code: Title 42 - THE PUBLIC HEALTH AND WELFARE

Title 45 published on 2015-10-01

The following are ALL rules, proposed rules, and notices (chronologically) published in the Federal Register relating to 45 CFR Part 170 after this date.

  • 2015-10-16; vol. 80 # 200 - Friday, October 16, 2015
    1. 80 FR 62602 - 2015 Edition Health Information Technology (Health IT) Certification Criteria, 2015 Edition Base Electronic Health Record (EHR) Definition, and ONC Health IT Certification Program Modifications
      GPO FDSys XML | Text
      DEPARTMENT OF HEALTH AND HUMAN SERVICES, Office of the Secretary
      Final rule.
      These regulations are effective January 14, 2016, except for § 170.523(m) and (n), which are effective on April 1, 2016. The incorporation by reference of certain publications listed in the rule is approved by the Director of the Federal Register as of January 14, 2016.
      45 CFR Part 170