Global: ^RA(78.3

FileMan FileNo	FileMan Filename	Package
78.3	DIAGNOSTIC CODES	Radiology Nuclear Medicine

FileMan FileNo

FileMan Filename

Package

78.3

DIAGNOSTIC CODES

Radiology Nuclear Medicine

Description

This file contains the diagnostic codes that can be associated with an exam. The code is attached to an exam at the same time the interpreting resident and/or staff physician is entered for the exam. The diagnostic code represents a quick overall summary of what the interpreting physician wrote in his/her report concerning the exam. [NOTE: Diagnostic code is not the impression. The impression is stored in the 'IMPRESSION' field of the 'RAD/NUC MED REPORTS' file (#74).] The following is the list of codes that are loaded when the module is initialized: 1) NORMAL 2) MINOR ABNORMALITY 3) MINOR ABNORMALITY, NO ATTN, NEEDED 4) ABNORMALITY, ATTN. NEEDED 5) MAJOR ABNORMALITY, PHYSICIAN AWARE 6) UNDICTATED FILMS NOT RETURNED, 3 DAYS 7) UNSATISFACTORY/INCOMPLETE EXAM 8) POSSIBLE MALIGNANCY, FOLLOW-UP NEEDED As part of the system customization process, these entries can be deleted. However, once the system is in production, you should 'not' delete any entries. Adding new entries is always allowed. If the site decides to enter diagnostic codes for exams, then database searches can be performed using the 'DIAGNOSTIC CODE' field of the exam record in the search criteria. For example, the database can be searched for all 'normal' chest procedures. Data Storage ------------ The data for the 'DIAGNOSTIC CODES' file is stored in the ^RA(78.3, global. At the present time this file is very static after day-one initialization is complete. However, it still should be journaled. It should also be translated if the operating system supports this function. Input Templates --------------- The package does not use any input templates associated with this file. Print Templates --------------- The following is a list of print templates used by the package: Name Description; Option(s) ---- ---------------------- DIAGNOSTIC CODE PRINT Prints a list of entries in this file; RA DIAGP Sort Templates -------------- The package does not use any sort templates associated with this file. APPLICATION GROUP(S): RA

Package	Total	Routines
Radiology Nuclear Medicine	5	RABIRAD RAHLO2 RAIPS211 RAMAIN RAMAINP
Oncology	1	ONCOCFR
Womens Health	1	WVALERTR

Package	Total	FileMan Files
Radiology Nuclear Medicine	3	RAD/NUC MED HL7 APPLICATION EXCEPTION(#79.7)[2.1, 2.2] RAD/NUC MED PATIENT(#70)[#70.03(13), #70.14(.01)] RAD/NUC MED REPORTS(#74)[#74.01(5), #74.16(.01)]
Imaging	2	IMAGING SITE PARAMETERS(#2006.1)[302] DICOM GATEWAY PARAMETER(#2006.563)[124]
DSS Extracts	1	RADIOLOGY EXTRACT(#727.814)[14]
Womens Health	1	WV DIAGNOSTIC CODE TRANSLATION(#790.32)[.02]

Package	Total	FileMan Files
Lexicon Utility	1	EXPRESSIONS(#757.01)[6]

Fields, Total: 8

Field #	Name	Loc	Type	Details
.001	NUMBER		NUMBER	INPUT TRANSFORM: `K:+X'=X!(X>998)!(X<1)!(X?.E1"."1N.N) X` LAST EDITED: `MAR 17, 2009` HELP-PROMPT: `Type a Number between 1 and 998, 0 Decimal Digits` DESCRIPTION: `This field contains the number of this diagnostic code. This provides a way to do quick look-ups of a diagnostic code by its number.` `Diagnostic code numbers are assigned by the system and are between 1 and 998. Diagnostic codes above 998 are assigned by Radiology patches.` `Code Number Usage` `----------- -------------------------` `999-1003 Nat'l Teleradiology Prog.` `1100-1106 BI-RADS` `1200-1202 Abdominal Aortic Aneurysm` TECHNICAL DESCR: `The maximum limit for this field is set to 998 by patch RA5.097.` `SOURCE OF DATA: SYSTEM GENERATED`
.01	DIAGNOSTIC CODE	0;1	FREE TEXT	**********************REQUIRED FIELD********************** INPUT TRANSFORM: `K:$L(X)>60!($L(X)<3)!'(X'?1P.E)!(X'?.ANP) X` LAST EDITED: `MAR 17, 2009` HELP-PROMPT: `Enter a short diagnostic code, between 3 and 60 characters in length, to indicate the results of the image analysis.` DESCRIPTION: `This field contains a short diagnostic code to indicate the results of the interpreting physician's analysis of the images. Diagnostic codes can be between 3 and 60 characters in length and can be used as a basis for` `database searches. (ie. How many 'Normal' chest exams were performed during a specific time period?)` `Eight diagnostic codes are included with the original package. Other site-specific diagnostic codes may be entered by the rad/nuc med coordinator at each site.` TECHNICAL DESCR: `This field is made uneditable by patch RA597.` `Patch RA5.097 adds BI-RADS codes to IEN 1100 thru 1106, and AAA codes to IEN 1200 thru 1202. Routine RABIRAD builds a string of BI-RADS IENs based upon the exact spelling of the first two words in this field, eg.` `"BI-RADS CATEGORY".` DELETE TEST: `1,0)= I 1 D EN^DDIOL("Diagnostic Codes cannot be deleted. Inactivate to remove.",,"!,$C(7)")` `SOURCE OF DATA: RAD/NUC MED COORDINATOR` `UNEDITABLE` CROSS-REFERENCE: `78.3^B` `1)= S ^RA(78.3,"B",$E(X,1,30),DA)=""` `2)= K ^RA(78.3,"B",$E(X,1,30),DA)` `Regular 'B' cross reference assigned by FileMan.`
2	DESCRIPTION	0;2	FREE TEXT	INPUT TRANSFORM: `K:$L(X)>80!($L(X)<1) X` LAST EDITED: `AUG 29, 1984` HELP-PROMPT: `Enter a description of the diagnostic code between 1 and 80 characters in length.` DESCRIPTION: `This field is used to give a description of the diagnostic code and may be from 1-80 characters in length.` `SOURCE OF DATA: RAD/NUC MED COORDINATOR`
3	PRINT ON ABNORMAL REPORT	0;3	SET	'Y' FOR YES; 'N' FOR NO; LAST EDITED: `NOV 15, 1994` HELP-PROMPT: `Enter 'Y' for YES if this code should print on the Abnormal Exam Report.` DESCRIPTION: `This field contains a 'Yes' or 'No' value to indicate if exams with this diagnostic code should be printed on the 'Abnormal Exam Report'. The report is used to ensure that the physician is notified of abnormal results of` `an exam. This field must be set to 'Yes' before the diagnostic code is entered on the exam in order for that exam to appear on the 'Abnormal Exam Report'.` `SOURCE OF DATA: RAD/NUC MED COORDINATOR`
4	GENERATE ABNORMAL ALERT?	0;4	SET	'y' FOR YES; 'n' FOR NO; LAST EDITED: `JUL 25, 1991` HELP-PROMPT: `Answering 'YES' indicates that whenever this diagnostic code is entered for a report an abnormal alert should be sent to the attending/requesting physician.` DESCRIPTION: `If this code should generate an abnormal alert, enter 'y', yes at this prompt.`
5	INACTIVE	0;5	SET	'Y' FOR YES; LAST EDITED: `DEC 23, 1996` HELP-PROMPT: `Enter Y to inactive this diagnostic code, or delete the Y to re-activate this code.`
6	*EXPRESSION	0;6	POINTER TO EXPRESSIONS FILE (#757.01)	EXPRESSIONS(#757.01) LAST EDITED: `SEP 08, 2023` HELP-PROMPT: `This field has been deprecated and should no longer be used.` DESCRIPTION: `This field has been deprecated.` `This field is associated with the .01 field used for BI-RADS codes under the MQSA coding system mandated by the FDA. Whenever the BI-RADS codes from field .01 is displayed, this field will be used to retrieve the current` `FDA-mandated wording for .01 field values of "BI-RADS CATEGORY 0" through "BI-RADS CATEGORY 6", which are in record numbers 1100 through 1106. The retrieved value will be displayed next to the .01 field value. This field` `is initially populated by patch RA5.097. The Radiology application does not prompt the user for this field. Changes to data in this field will be made by future Radiology patches.` TECHNICAL DESCR: `This field is being decommissioned by patch RA5.0206. It will replaced by a new DISPLAY TEXT field. This field will be deleted after 18 months.` `This field was added and made uneditable by patch RA5.097.` `UNEDITABLE`
100	DISPLAY TEXT	1;E1,245	FREE TEXT	INPUT TRANSFORM: `K:$L(X)>245!($L(X)<1) X` `MAXIMUM LENGTH: 245` LAST EDITED: `SEP 08, 2023` HELP-PROMPT: `Enter the display text of the diagnostic code between 1 and 245 characters in length. Data for this field must be entered by a Radiology patch.` DESCRIPTION: `This field is associated with the BI-RADS codes under the MQSA coding system mandated by the FDA. Whenever the BI-RADS codes from field .01 is displayed, this field will be used to display the current FDA-mandated wording` `for .01 field values of "BI-RADS CATEGORY 0" through "BI-RADS CATEGORY 6", which are in record numbers 1100 through 1106 and 1110. The retrieved value will be displayed next to the .01 field value. This field is initially` `populated by patch RA5.0206. The Radiology application does not prompt the user for this field. Changes to data in this field will be made by future Radiology patches.` TECHNICAL DESCR: `This field is replacing the EXPRESSION field (#6), which has been marked for deletion.` `This field was added and made uneditable by patch RA5.0206.` `UNEDITABLE`

DIAGNOSTIC CODE: NORMAL	DIAGNOSTIC CODE: MINOR ABNORMALITY	DIAGNOSTIC CODE: MAJOR ABNORMALITY, NO ATTN. NEEDED	DIAGNOSTIC CODE: ABNORMALITY, ATTN. NEEDED	DIAGNOSTIC CODE: MAJOR ABNORMALITY, PHYSICIAN AWARE	DIAGNOSTIC CODE: UNDICTATED FILMS NOT RETURNED, 3 DAYS	DIAGNOSTIC CODE: UNSATISFACTORY/INCOMPLETE EXAM	DIAGNOSTIC CODE: POSSIBLE MALIGNANCY, FOLLOW-UP NEEDED
DIAGNOSTIC CODE: TELERADIOLOGY, NOT YET DICTATED	DIAGNOSTIC CODE: NO ALERT REQUIRED	DIAGNOSTIC CODE: SIGNIFICANT ABNORMALITY, ATTN NEEDED	DIAGNOSTIC CODE: CRITICAL ABNORMALITY	DIAGNOSTIC CODE: POSSIBLE MALIGNANCY	DIAGNOSTIC CODE: BI-RADS CATEGORY 0	DIAGNOSTIC CODE: BI-RADS CATEGORY 1	DIAGNOSTIC CODE: BI-RADS CATEGORY 2
DIAGNOSTIC CODE: BI-RADS CATEGORY 3	DIAGNOSTIC CODE: BI-RADS CATEGORY 4	DIAGNOSTIC CODE: BI-RADS CATEGORY 5	DIAGNOSTIC CODE: BI-RADS CATEGORY 6	DIAGNOSTIC CODE: BI-RADS CATEGORY R	DIAGNOSTIC CODE: BI-RADS CATEGORY 0	DIAGNOSTIC CODE: ALMOST ENTIRELY FATTY	DIAGNOSTIC CODE: SCATTERED AREAS OF FIBROGLANDULAR DENSITY
DIAGNOSTIC CODE: HETEROGENEOUSLY DENSE	DIAGNOSTIC CODE: EXTREMELY DENSE	DIAGNOSTIC CODE: ABDOMINAL AORTIC ANEURYSM NOT PRESENT	DIAGNOSTIC CODE: ABDOMINAL AORTIC ANEURYSM PRESENT	DIAGNOSTIC CODE: DOES NOT SATISFY SCREEN FOR AAA	DIAGNOSTIC CODE: LUNGRADS 0: INCOMPLETE	DIAGNOSTIC CODE: LUNGRADS 1: NEGATIVE	DIAGNOSTIC CODE: LUNGRADS 2: BENIGN APPEARANCE OR BEHAVIOR
DIAGNOSTIC CODE: LUNGRADS 3: PROBABLY BENIGN	DIAGNOSTIC CODE: LUNGRADS 4A: SUSPICIOUS	DIAGNOSTIC CODE: LUNGRADS 4B: SUSPICIOUS	DIAGNOSTIC CODE: LUNGRADS 4X: SUSPICIOUS WITH ADDITIONAL FEATURES	DIAGNOSTIC CODE: LUNGRADS S: SIGNIFICANT INCIDENTAL FINDING	DIAGNOSTIC CODE: LUNGRADS C: PRIOR LUNG CANCER	DIAGNOSTIC CODE: PR 1	DIAGNOSTIC CODE: PR 2A
DIAGNOSTIC CODE: PR 2B	DIAGNOSTIC CODE: PR 3A	DIAGNOSTIC CODE: PR 3B	DIAGNOSTIC CODE: PR 4A	DIAGNOSTIC CODE: PR 4B	DIAGNOSTIC CODE: NVCC	DIAGNOSTIC CODE: VACAA	DIAGNOSTIC CODE: CONTRACT
DIAGNOSTIC CODE: NOT ORDERED BY VA	DIAGNOSTIC CODE: INCIDENTAL LUNG NODULE(NONSCREENING)	DIAGNOSTIC CODE: LI-RADS NC	DIAGNOSTIC CODE: LI-RADS NO OBS	DIAGNOSTIC CODE: LI-RADS 1	DIAGNOSTIC CODE: LI-RADS 2	DIAGNOSTIC CODE: LI-RADS 3	DIAGNOSTIC CODE: LI-RADS 4
DIAGNOSTIC CODE: LI-RADS 5	DIAGNOSTIC CODE: LI-RADS TIV	DIAGNOSTIC CODE: LI-RADS M	DIAGNOSTIC CODE: LI-RADS TR NONEVALUABLE	DIAGNOSTIC CODE: LI-RADS TR NONVIABLE	DIAGNOSTIC CODE: LI-RADS TR EQUIVOCAL	DIAGNOSTIC CODE: LI-RADS TR VIABLE	DIAGNOSTIC CODE: US LI-RADS 1A
DIAGNOSTIC CODE: US LI-RADS 1B	DIAGNOSTIC CODE: US LI-RADS 1C	DIAGNOSTIC CODE: US LI-RADS 2A	DIAGNOSTIC CODE: US LI-RADS 2B	DIAGNOSTIC CODE: US LI-RADS 2C	DIAGNOSTIC CODE: US LI-RADS 3A	DIAGNOSTIC CODE: US LI-RADS 3B	DIAGNOSTIC CODE: US LI-RADS 3C
DIAGNOSTIC CODE: PI-RADS NC	DIAGNOSTIC CODE: PI-RADS 1	DIAGNOSTIC CODE: PI-RADS 2	DIAGNOSTIC CODE: PI-RADS 3	DIAGNOSTIC CODE: PI-RADS 4	DIAGNOSTIC CODE: PI-RADS 5	DIAGNOSTIC CODE: TI-RADS NC	DIAGNOSTIC CODE: TI-RADS 1
DIAGNOSTIC CODE: TI-RADS 2	DIAGNOSTIC CODE: TI-RADS 3	DIAGNOSTIC CODE: TI-RADS 4	DIAGNOSTIC CODE: TI-RADS 5

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Package: Radiology Nuclear Medicine

Global: ^RA(78.3

Information

Description

Accessed By FileMan Db Calls, Total: 7

Pointed To By FileMan Files, Total: 7

Pointer To FileMan Files, Total: 1

Fields, Total: 8

Found Entries, Total: 84