Procedure

Reference data for clinical procedures with standardized coding (CPT, ICD-10-PCS, SNOMED CT). Defines procedure categories, body sites, specialties, durations, and anesthesia requirements for scheduling and documentation.

Overview

Procedure provides standardized definitions of clinical procedures from simple office visits to complex surgeries. Each procedure type includes coding, category (surgical, diagnostic, therapeutic), associated body site, typical specialty, duration, and anesthesia requirements. This reference data supports procedure scheduling, surgical planning, billing, and clinical documentation.

Key Concepts

Procedure Categories

The category field classifies procedure purpose:

Category	Description	Examples
`surgical`	Operative procedures	Cholecystectomy, appendectomy
`diagnostic`	Procedures to diagnose	Biopsy, endoscopy, catheterization
`therapeutic`	Treatment procedures	Stent placement, ablation
`preventive`	Preventive interventions	Vaccination, screening
`palliative`	Comfort/symptom relief	Nerve block, drainage

Coding Systems

The system field identifies the terminology:

System	Use Case	Example
`CPT`	Professional billing	47562
`ICD-10-PCS`	Inpatient procedures	0FB44ZX
`SNOMED-CT`	Clinical documentation	45595009
`HCPCS`	Medicare/equipment	G0105

Body Site

Links to HealthReferenceBodySite:

Anatomical location of procedure
Supports surgical planning
Guides positioning and prep
Informs consent documentation

Specialty Association

Links to HealthReferencePractitionerSpecialty:

Typical performing specialty
Credentialing requirements
Referral routing
Quality metrics by specialty

Anesthesia Requirements

The requiresAnesthesia field indicates:

Whether anesthesia support needed
Local vs general considerations
Pre-operative clearance needs
NPO requirements
Recovery room planning

Typical Duration

The typicalDurationMinutes field:

Expected procedure length
OR scheduling optimization
Resource allocation
Recovery time planning

Use Cases

Procedure Scheduling

When scheduling procedures:

Look up procedure by code
Check anesthesia requirements
Allocate appropriate time slot
Assign to qualified provider
Schedule pre-op workup if needed

Surgical Planning

For operative cases:

Reference procedure duration
Plan OR resources
Coordinate anesthesia
Ensure specialty coverage
Prepare equipment/supplies

Pre-Authorization

For insurance approval:

Map procedure to CPT code
Document medical necessity
Submit with diagnosis codes
Track approval status
Update billing system

Consent Documentation

When obtaining consent:

Reference procedure description
Document body site/laterality
Explain anesthesia plan
Discuss specialty-specific risks
Obtain signed consent

Quality Reporting

For quality metrics:

Track procedures by type
Calculate outcomes by category
Monitor complications
Benchmark duration against typical
Report by specialty

Related Entities

Entity	Relationship	Description
HealthReferenceBodySite	References	Anatomical site
HealthReferencePractitionerSpecialty	References	Performing specialty
ClinicalNote	Referenced by	Procedure notes document these

Enums

system

Value	Description
`CPT`	Current Procedural Terminology - AMA billing codes
`ICD-10-PCS`	ICD-10 Procedure Coding System for inpatient procedures
`SNOMED-CT`	Systematized Nomenclature of Medicine Clinical Terms
`HCPCS`	Healthcare Common Procedure Coding System for Medicare
`other`	Other coding system not listed

Value	Description
`surgical`	Operative procedures requiring incision or instrumentation
`diagnostic`	Procedures performed to establish a diagnosis
`therapeutic`	Procedures performed to treat a condition
`preventive`	Procedures to prevent disease or detect early
`palliative`	Procedures focused on symptom relief and comfort
`other`	Other procedure category not listed

Properties

Property	Type	Mode	Description	Required
code	string	stored	Standardized procedure code Example: `"47562"`	Required
system	string	stored	Coding system used Values: `CPT, ICD-10-PCS, SNOMED-CT, HCPCS, other` Example: `"CPT"`	Required
label	string	stored	Human-readable name of the procedure Example: `"Laparoscopic cholecystectomy"`	Required
category	string	stored	Category of procedure Values: `surgical, diagnostic, therapeutic, preventive, palliative, other` Example: `"surgical"`	Optional
bodySite	HealthReferenceBodySite	stored	Primary body site for the procedure	Optional
specialty	HealthReferencePractitionerSpecialty	stored	Medical specialty typically performing this procedure	Optional
typicalDurationMinutes	number	stored	Typical duration of the procedure in minutes Example: `90`	Optional
requiresAnesthesia	boolean	stored	Whether the procedure typically requires anesthesia Example: `true`	Optional
description	string	stored	Additional details about the procedure	Optional

Examples

Example 1

{
  "@type": "Procedure",
  "code": "47562",
  "system": "CPT",
  "label": "Laparoscopic cholecystectomy",
  "category": "surgical",
  "typicalDurationMinutes": 90,
  "requiresAnesthesia": true,
  "description": "Minimally invasive surgical removal of the gallbladder"
}

Example 2

{
  "@type": "Procedure",
  "code": "43239",
  "system": "CPT",
  "label": "Upper GI endoscopy with biopsy",
  "category": "diagnostic",
  "typicalDurationMinutes": 30,
  "requiresAnesthesia": true,
  "description": "Esophagogastroduodenoscopy with tissue sampling"
}

Example 3

{
  "@type": "Procedure",
  "code": "99213",
  "system": "CPT",
  "label": "Office visit, established patient, low complexity",
  "category": "diagnostic",
  "typicalDurationMinutes": 15,
  "requiresAnesthesia": false,
  "description": "Outpatient evaluation and management visit"
}