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Comment: Updated COPD-OSA example to include Sept 2020 FHIR Connectathon example fixes.


  • Gather data from: Wound care implementation guide/data set, ADA?
  • Persona: 82 yo F Glenda Goodwitch with insulin-dependent DM for 19 years, has multiple complications including chronic  wounds and retinopathy
  • Coverage transition: MA to MA


***Scenario 2 PCDE Bundle Example here (TBD).

Diagnosis Codes:

Diabetes Mellitus: SNOMED-CT 237599002 | Insulin treated type 2 diabetes mellitus (disorder) or ICD-10-CM E11.65 “Type 2 diabetes mellitus with other specified complications.”


  • Goal:
    • Diabetes Glucose Control: Hba1c <7.5
    • Not achieved
    • Wound Care: Closure of foot ulcer
    • Not achieved
  • Provider: Dokter Bronsig
  • Active Treatments: relevant metadata – schedule, supplier, duration of therapy, ordering provider
  • Non-DME Supplies: 
    • Diabetes: 
      • Glucose testing strips

        Blood glucose testing stripsHCPCSA4253Blood glucose test or reagent strips for home blood glucose monitor, 50 strips

        Unclear how often this order renews or how many units are provided at once

      • Lancets

        LancetsHCPCSA4259Lancets, per box of 100

        Unclear how often this order renews or how many units are provided at once

      • Syringes with needles

        SyringesHCPCSS8490Insulin syringes (100 syringes, any size)

        Unclear how often this order renews or how many units are provided at once

    • Wound care: this care plan may be optional in this use case?
  • DME:
    • Glucometer–investigate coverage patterns for glucometers

      GlucometerHCPCSE0607Home blood glucose monitor

      this is technically a device-- is this the correct code?

  • Medications:

    • Humalog SSI

      Lispro SSINDC00027510011 VIAL in 1 CARTON > 10 mL in 1 VIALINSULIN LISPRO 100 [iU]/mL, syn Humalog

      Sliding scale sq TIDAC, for BG<180 0 units, for BG180-240 2 units, for BG 241-300 4 units, for BG301+ 6 units, for BG>400, call MD

      Lispro SSIRxNorm242120insulin lispro 100 UNT/ML Injectable Solution

    • Lantus 40 u BID

      LantusNDC000885020011 SYRINGE in 1 PACKAGE > 3 mL in 1 SYRINGE3 ML Insulin Glargine 100 UNT/ML Pen Injector [Lantus]40 u sq BID
      Lantus solostar

    • Exenatide BID

      ExenatideNDC03106520041 CARTRIDGE in 1 TRAY > .65 mL in 1 CARTRIDGEexenatide Pen Injector

      5mcg BIDAC (2x/day) sq


      exenatide Pen Injector

    • Antibiotics*-- fixed duration ? – can use for future use case with active treatment that is temporary
    • Bacitracin?
  • Diabetes Care Management Program – from payer, provider, outside resource? would all data be similarly available?

    Chronic Care Management, Diabetes and wound care,CPT99487Complex chronic care management services, with the following required elements: ● Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient ● Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline ● Establishment or substantial revision of a comprehensive care plan ● Moderate or high complexity medical decision making ● 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month

    Not sure this is the right code-- would payer care managment be physician supervised? Can this be billed remotely?

  • Specialty Care: Ophthalmology-- may require procedures to treat, unclear if these would be scheduled

    Opthalmology consultSNOMED-CT183543004Ophthalmological referralActive referral, not yet seen: to Joe See, MD, ophthalmology, referral for eye exam with retinal imagingWithin next 3 months
    • Could consider CKD/renal as part of this use case
  • Ancillary Care: Wound care, Home RN – consider how to categorize ancillary care vs home services

    Home health wound therapyCPT97597Wound therapy, home

    CPT Codes 97597 and 97598 are considered “sometimes” therapy codes. If billed by a physical therapist when the patient is under a home health benefit, it may be covered by the Home Health agency, if part of their Plan of Care. If it is a physician or nonphysician practitioner that is billing these “sometimes” therapy codes, it is paid under Part B even if the beneficiary is under an active home health plan of care.

  • Prior authorizations: 
  • Exenatide-- 06/11/2019-06/11/2020

Persona / Use Case Scenario


  • Persona: 55 yo with liver transplant for Non-alcoholic steatohepatitis (NASH), comorbid depression
  • Coverage Transition: Commercial to Commercial
  • Diagnosis Codes: TBD
  • Active Treatments:
  • Medications:
    • Immunosuppression
  • Counseling/mental health services
  • Substance abuse follow up
  • Specialty Care: Transplant Surgery
  • Transplant Coordinator and Care Management
  • Past treatments? – Transplant surgery, pre-transplant therapy?
  • Prior authorizations
  • Notes from discussion: 
  • What is the role of supplemental coverage? Would they have clinical data relevant to these use cases or the exchange of data?
  • Past Medical History: what if any PMH should be transmitted? How do we determine what is relevant and what is not
    • PMH will be transmitted in as much as it is relevant to current conditions/treatments


#3  Need for continuing a medication protocol (chemotherapy regimen)

This persona focuses on identifying the member continuing a chemotherapy regimen at the time of health plan transition. A protocol regimen identifies a combination of drugs that are given in cycles in order to achieve a line of therapy. It is important to note the name of the chemotherapy regimen as well as supporting information that justifies the regimen can be administered. As a result, this persona should contain additional information like lab results, procedures, and other clinical indicators showing that the patient's qualification for such a regimen.


  • Alice N. Wonderland is a 70 year old female diagnosed with Stage IV HER2 Positive Breast Cancer. She is currently undergoing the second of 6 cycles of a single-agent chemotherapy regimen for Kadcyla (Ado-trastuzumab emantisine, T-DM1)).

***Scenario 3 PCDE Bundle Example here (TBD).

Supporting information:

  • Demographics:
    • Name: Alice N. Wonderland
    • Birth date: 1950-04-18
    • Gender: female
  • Medical Oncologist:
    • Kyle Anydoc, MD
    • NPI: 9988776655
  • Old health plan:
    • com
  • Active Treatment
    • NCCN breast cancer chemotherapy regimen ID: BRS89
      • Kadcyla - Ado-trastuzumab emtansine (T-DM1) – HCPCS: J9354 , RxNorm: 1658091 
        • 6 mg/kg IV day 1
        • Cycled every 21 days
      • PriorAuthorization required for Kadcyla approval.
    • Diagnosis
      • (reasonCode: 511, Malignant neoplasm of lower-outer quadrant of right female breast)
      • Secondary dx code: 0 – Estrogen receptor positive status [ER+].
    • ServiceRequest: Echocardiogram
    • ServiceRequest: CMP
    • Supporting Information:
      • Lab test: HER2 IHC (LOINC 18474-7), result = 3+
      • ECOG performance score (LOINC 89247-1), result = 1
      • Lab test: LVEF (LOINC 10230-1), result = 65%