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Table of Contents

**UPDATED Virtual Connectathon information** 

May 13-15th, 2020

Registration cost: $100 for HL7 Members; $150 for non-members

Registration link: Connectathon 24 Confluence page

'Dental' Zulip stream (chat.fhir.org): https://chat.fhir.org/#narrow/stream/179292-dental

Dental Track Orientation: 5/11/2020 1:00pm EST.

Participation Information

Phone Number: +1 646-558-8656
Participant Passcode: 891 635 8003

Web Meeting Info

Join Zoom Meeting - https://zoom.us/j/8916358003?pwd=MEFHYzBMN1A5TmZVTmRUbm92TkR5dz09

Meeting ID: 891 635 8003  Password: 346111 | +1 646 558 8656 US (New York) | Find your local number: https://zoom.us/u/ab7jlUwcTc


Daily Connectathon schedule

Track kick-off 5/13 at 4:00pm EST. Meeting link to be posted here

5/14 we'll begin at 10:00am EST

All feedback on the FHIR Dental Exchange specification can be directly submitted to the HL7 Jira FHIR Specification Feedback page (instructions: Specification Feedback)


Dental Data Exchange FHIR IG: https://build.fhir.org/ig/HL7/dental-data-exchange/

Testing Resources:

Submitting WG/Project/Implementer Group

Payer/Provider Information Exchange WG

Justification and Objectives

This track aims to demonstrate the exchange of information between dental and medical providers for a patient. Relevant FHIR resources will be based largely on existing US Core and CCDA on FHIR. This work will inform the development of more comprehensive implementation guides and profiles for interoperability between dental to medical and dental to dental domains based on FHIR Release 4, which is the primary target for the dental exchange testing in this track.

This track will use the R4 version of FHIR.

Clinical input requested

Clinical input has been gathered from medical and dental stakeholders throughout the development of this track proposal and is reflected in the scenarios (use cases) below.

Related tracks

Care Management Track

US Core Track

Proposed Track Lead

Dave deRoode - david.deroode@lantanagroup.com

Zabrina Gonzaga - zabrina.gonzaga@lantanagroup.com

Expected participants

  • Rebekah Fiehn, DentaQuest
  • Corporate Dental System (CDS)
  • Cerner/Dentrix/Henry Schein One
  • DSS (VA Dental Record Manager)
  • Gregory Zeller (ADA)
  • Jean Narcisi (ADA)
  • Sharon Stanford (ADA)
  • LTC Kevin Parker (U.S. Army)
  • Add your name here

Track Orientation

A webinar will be hosted on date at time to share further participation information about this track.

System Roles

  • Medical Provider (‘M’)/Referral Coordinator record system – POST and GET Referral request note to/from FHIR server (Medical to Dental)
  • Dental Provider (‘T’) record system – POST and GET ‘Dental Referral Treatment Report to/from FHIR server (Dental to Medical; Dental to Dental)

Your system should be capable of handling/supporting FHIR bundle containing some of the entries listed within the tables


Scenarios

Info

There are 4 possible scenarios in this Connectathon track. Not all scenarios apply to all systems/actors.


Scenario 1: Medical to Dental referral

Patient A is a 21-year-old white Hispanic male with mild hypertension who is a full time white-collar worker, recently graduated from college. He is seeing Dr. M at Good Health Clinic, his established primary care physician for a routine, annual check-up.

Upon arrival, the receptionist

  1. reviews his insurance card, a commercial plan offered through his employer;
  2. provides Patient A with a routine oral health assessment questionnaire;
  3. updates the patient demographic (update Patient resource);
  4. updates insurance information (update Coverage); ***clarify health vs. dental insurance; presumably, dental insurance info might be used for exchange between dentist/endodontist (use cases 3/4)***
  5. collects patient's co-pay.

The medical assistant takes the patient to the examination area calls the patient back and 

  1. obtains Patient A’s vital signs (create Observations),
  2. obtains medical history (Hypertension diagnosis/Condition);
  3. obtains current medications (update Medication);
  4. asks for any concerns (create Condition) to discuss with the provider today (e.g. such as 'bleeding gums'). 

Among the issues raised by Patient A is increasing pain in his left lower jaw and some occasional bleeding from his gums (Conditions, Observations).

Note that the standard sections of the electronic health record (EHR) contain the routine oral health information formerly captured in the Oral Health Risk Assessment (18+). (RiskAssessment)

***Need to discuss codes for various riskAssessments in scope; Also, need to complete outcome prediction elements***

During the visit, Dr. M

  1. reviews the information with Patient A;
  2. performs an exam of his oral and paraoral areas health. Upon oral examination, Dr. M finds the patient has swollen gums, significant plaque buildup and significant tenderness near left lower molar (Condition, Observation); 
  3. confirms the patient has not visited a dentist or received fluoride treatmentsin the past four years while away at college;
  4. advises (Communication) Patient A to see a dentist regularly, brush his teeth twice a day with fluoride toothpaste, and floss daily;
  5. makes an urgent referral (ServiceRequestReferral Note) to a dentist for further evaluation and discusses the plan with Patient A, who concurs;
  6. generates a ‘CCDAonFHIR Referral note’ (Bundle.type=document) that includes the below FHIR coded information as well as the accompanying narrative (CCDA-on-FHIR Composition) describing the dental-related findings.

Before leaving, the practice’s referral coordinator schedules an appointment for Patient A to see Dentist D for the next day.

The patient checks out and schedules a follow-up appointment with Dr. M in three months (Encounter, planned).  Bundle.type=document is generated by Dr. M’s EHR system and is received by Dentist D’s system.

Actor: Medical Provider

**For General Clinical terminology mappings to FHIR resources, see: https://www.hl7.org/fhir/resourceguide.html. For example, there is no Chief Complaint resource, so this information will be found in a Condition resource.

Resource/Profile

*indicates non-US Core profile)

US Core:

Data Element

Sample Data

Codes

AllergyIntollerance

AllergyIntollerance.code

Penicillin

RxNorm

7908 Penicillin G (Ingredient)

Communication*

Communication.payload.content

Pt. Education. Advised to see dentist regularly, brush 2x/day w/ fluoride toothpaste, floss

NA (text)

Chief Complaint  (Condition)

Tooth pain in left lower jaw 


Bleeding gums, occasional 


27355003 Pain in tooth;

301716002 Left lower quadrant pain

86276007 Bleeding gums;

4638005 Occasional

Physical Exam Findings - Oral Health Exam
Findings:  swollen gums, significant plaque buildup and significant tenderness near left lower molarICD

SDT 108723D Teeth covered in plaque (finding)

SCT 276453000 Teeth covered in plaque (finding)

ICD K03.6 Deposits [accretions] on teeth

SDT 131687D Toothache (finding)

SCT 27355003 Toothache (finding)

ICD K08.89 Other specified disorders of teeth and supporting structures

SDT 148393D Swollen gums 

SCT 309685001 Swollen gums

ICD K06.8 Other specified disorders of gingiva and edentulous alveolar ridge


 Medical History

the patient has not visited a dentist or received fluoride treatments in the past four years while away at college

Tobacco status here? Or in social history? Or not at all?

For Text, to discuss at Connectathon

Coded Resource will use US Core Smoking Status Observation profile

Refer for D0150 

I agree, omit:  68071007 | Dental fluoride treatment (procedure) | - use a negationInd?

If a visit or procedure has not occurred (to the knowledge of the documenting provider), I think omitting it entirely is more accurate. If a provider wishes to make assertion that something was NOT done, and it is important to communication that it needs to be done, this can be acheived through using .status (which is optional currently).

Condition

Condition.category

Condition.code


Mild, Hypertension

 

SDT 175027D Hypertensive disorder (disorder)

SCT 38341003 Hypertensive disorder (disorder)

ICD I10 Essential (primary) hypertension


Coverage*

(See below)

Coverage.status

Coverage.payor

reviews his insurance card, a commercial plan offered through his employer


Encounter

Encounter.status

Encounter.class **TODO: Discuss .class**

Encounter.type

Encounter.period

Encounter.priority

Office visit: Feb 14, 2020 at 3:00 pm - routine

Dental Referral: Feb 15, 2020 at 3 pm; priority – urgent


3 month follow-up: May 15, 2020

CPT: 99201 Office Visit

(HL7 v3 CodeSystem ActPriority)

Medication & MedicationRequest (status=completed)

Medication.code

MedicationRequest.status

Medicationstatus.intent

MedicationRequest.authoredOn

MedicationRequest.dosageInstruction.route

MedicationRequest.dosageInstruction.doseAndRate

Lisinopril 10 mg tab, taking 1 tab once a day

RxNorm - 314076 Lisinopril 10 mg Oral Tablet

Organization

Organization.identifier:NPI

Organization.active

Organization.name

1316452725

Active=true

Good Health Clinic

National Provider Index

Patient

Patient.name

Patient MRN (identifier)

Patient.address

Patient.telecom

Patient.birthDate

Patient.gender

Patient.us-core-ethnicity (extension)

Patient.us-core-race (extension)

Patient A

MRN: 5152020

123 Test. Dr. Denver CO 80204

phone: (123)456-7890

email: testA@email.com

01-01-1990

Male

Hispanic or Latino

White

us-core-race & ethnicity (omb)

Hispanic or Latino (2135-2 OmbEthnicityCategories)

White (2106-3 OmbRaceCategories)

AdministrativeGender- male

Coverage

Coverage.status

Coverage.payor

Aetna Comprehensive Medical /Dental Insurance

TODO: Re-slice Referral Note section to include Insurance info


Practitioner

Practitioner.identifier:NPI

Practitioner.name

Practitioner Organization

123-456-7411

Dr. John M

Good Health Clinic


PractitionerRole

PractitionerRole.organization

PractitionerRole.code

Primary Care Physician

Healthcare Provider Taxonomy (HIPPA)

261Q00000X Ambulatory Health Care Facilities; Clinic/Center

Provider Role (HL7)

RP - Referring Provider

Referral Note (CCDAonFHIR) Reason for Referral

Composition.section.code[43241-9].text

Composition.section.code[43241-9].entry


Reason for Referral (text)

27355003 Pain in tooth

301716002 Left lower quadrant pain

86276007 Bleeding gums;

4638005 Occasional

D0150 (from Table below.)

RiskAssessment*

RiskAssessment.condition

RiskAssessment.basis

RiskAssessment.prediction.qualitativeRisk

Perio risk assessment

Caries risk assessment

(allow for nullFlavor is RiskAssessment was not performed)


** TODO get codes for various risk assessments **

SDT 116957D Chronic periodontitis (disorder)

SCT 5689008 Chronic periodontitis (disorder)

ICD K05.30 Chronic periodontitis, unspecified

SDT 179051D At high risk for dental caries (finding)

SCT 609402003 At high risk for dental caries (finding)

ICD Z91.843 Risk for dental caries, high

(allow for nullFlavor is RiskAssessment was not performed)


ServiceRequest*

ServiceRequest.priority

ServiceRequest.reasonCode


Dental Consult - urgent

Significant plaque buildup 

**For Connectathon discusion: plaque buildup vs. D0150 (both?)

Request Priority (routine, urgent, asap, stat)

Medical to Dental Reason for Referral valueset

(D0150? only or from above?

27355003 Pain in tooth

301716002 Left lower quadrant pain

86276007 Bleeding gums;

4638005 Occasional

D0150 (from Table below.))


Social History

College Education

Full-time employee:  accountant

Added Dependency on Occupation Data for Health OG; use Pat-or-Present-Job profile:

http://hl7.org/fhir/us/odh/StructureDefinition-odh-PastOrPresentJob.html
224302000 | Received higher education college education (finding)
106302007 | Accountant (occupation) |

Smoking Status: not-smoker

Vital Signs Observation 

Observation.component.value

Temp: 98.5

Pulse: 78

Respiration: 20

LOINC

8310-5 Body Temperature

8867-4 Heart rate

9279-1 Respiratory Rate


Value set:  Vital Sign Result Type urn:oid:2.16.840.1.113883.3.88.12.80.62





Success Criteria

For Medical systems: Medical Record (EHR) system able to generate bundle (referral note) above and successfully POST to test (HAPI) server

Medical Record (EHR) system able to GET bundle above bundle from test (HAPI) server

For Dental systems: Dental record system successfully GETs above bundle

Bonus point

Dental record system able to parse bundle entries and successfully store entry data


Scenario 2: Dental to Medical Consult Note

Patient A is a 21-year-old Hispanic male with mild hypertension who is seeing Dentist D for an urgent evaluation based on a referral from Dr. M, his primary care physician.

The receptionist

  1. checks in Patient A;
  2. since Patient A is new, creates a new patient record (create Patient)
  3. verifies the patient’s demographic and insurance information from the electronic referral received.

The dental hygienist

  1. calls the patient into the treatment area;
  2. verifies patient identity;
  3. obtains Patient A’s medical/social history;
  4. reviews the current medications (read Medication & MedicationRequest) and allergies (read AllergyIntollerance) from the referral note;
  5. confirms the reason (Composition.Reason for Referral) for this urgent visit.

Dentist D

  1. reviews the Risk Assessment; **TODO: RiskAssessment Details; Caries vs. General vs. Perio**
  2. reviews referral note from Dr. M;
  3. reviews the information pre-populated in his EHR;
  4. performs an oral evaluation (Procedures, generates Observations + new) - D0140, and exposed two PA radiographs (#18 D0220 and #7 D0230)
  5. identifies two areas of concern: The patient has a significant, non-restorable caries lesion (decay) on the left lower back molar (tooth #18) with signs of infection and also has early signs of decay on the right upper incisor (tooth #7) (Conditions). Patient reports inability to chew on left side due to pain and sensitivity, a condition that has increased in severity in the two days since his medical appointment;
  6. discusses findings with the patient;
  7. recommends an extraction of the left lower molar (tooth #18) and restoration of the right upper lateral incisor (tooth #7) due to a caries lesion (decay) (Procedure);
  8. educates (Communication) Patient A on the benefits of complete examination (dental home), of using a fluoride toothpaste when brushing twice daily with daily flossing, and of the need for bi-annual dental visits for examination and prophylaxis (cleaning).

Patient A agrees with the plan and agrees to schedule the follow-up procedures.

Dentist D

  1. reviews the patient’s current medication list (reads MedicationRequest);
  2. notes an allergy to penicillin (AllergyIntollerance) that is a counter-indication for his typical recommendation of amoxicillin;
  3. prescribes (create new MedicationRequest) Patient A erythromycin 500 mg every six hours for the infection and recommends alternating over-the-counter ibuprofen and acetaminophen for pain.

Patient

  1. schedules (create planned Encounter) the extraction of tooth #18 one week after initial appointment;
  2. schedules an appointment for restoration of tooth #7 for one week after extraction;
  3. schedules a follow-up for complete examination, including radiographs, and prophylaxis (cleaning) for one week after restoration of #7.

Dentist T generates a Dental Referral Treatment Report (Bundle.type=document) back to Dr. M with a summary of the visit which includes the new prescription (based on US Core Medication & MedicationRequest profile), planned procedures and dates (based on US Core Procedure profile).


Resource/Profile

Data Element

Sample Data

Codes

AllergyIntollerance

AllergyIntollerance.code

Penicillin

RxNorm

7908 Penicillin G (Ingredient)

Condition

Condition.code

Condition.bodySite

  • significant decay on the left lower second molar (tooth #18)  with signs of infection 
  • early signs of a caries lesion (decay) on the right upper lateral incisor (tooth #7) (code?)

Patient reports inability to chew on left side due to pain and sensitivity, a condition that has increased in severity in the two days since his medical appointment (code?)

SDT 212082D Significant

SDT 118065D Dental caries 

SDT 161372D Entire permanent mandibular left second molar tooth (body structure); Tooth number 18

SDT 181608D Infection of tooth


SDT 118065D Dental caries 

SDT 161941D Entire permanent maxillary right lateral incisor tooth (body structure); Tooth number 7


SDT 126488D Unable to chew

SDT 166427D Left side

SDT 130348D Oral pain

SDT 212084D Sensitivity

SDT 212088D Symptom severity

SDT 212090D Since last appointment


SCT 245574002 Entire permanent maxillary right lateral incisor tooth (body structure); Tooth number 7


SCT 80967001 Dental caries (disorder)

ICD K02.9 Dental caries, unspecified

SCT 245603001 Entire permanent mandibular left second molar tooth (body structure); Tooth number 18

SDT 108723D Teeth covered in plaque (finding)

SCT 276453000 Teeth covered in plaque (finding)

ICD K03.6 Deposits [accretions] on teeth

SDT 131687D Toothache (finding)

SCT 27355003 Toothache (finding)

ICD K08.89 Other specified disorders of teeth and supporting structures


SDT 116957D Chronic periodontitis (disorder)

SCT 5689008 Chronic periodontitis (disorder)

ICD K05.30 Chronic periodontitis, unspecified 

Consult Note (CCDAonFHIR)

Composition.Reason for Visit Section

Composition.Assessment and Plan section

Dental Consult

Recommend an extraction of the left lower second molar(tooth #18)  and a restoration on the right upper lateral incisor (tooth #7) due to a caries lesion

**Compare against Composition-2 section content**


Communication

Communication.payload

Patient education

 Patient A educated on the benefits of using a fluoride toothpaste, daily flossing, and bi-annual routine dental cleaning visits.

**What CCDA Section?**

(text)

Coverage

Coverage.status

Coverage.payor

reviews his insurance card, a commercial plan offered through his employer

Aetna Comprehensive Medical /Dental Insurance

TODO: Re-slice Section.Insurance


Encounter

Encounter.status

Encounter.period

Scheduled molar extraction and restoration #7 in one month

Follow-up for complete examination and cleaning (prophylaxis) in 6 months

**Need to confirm encounter code for planned follow-up and cleaning (prophylaxis) 209670D**

SDT 212092D Patient asked to make an appointment

CDT D0150 comprehensive oral evaluation - new or established patient

CDT D1110 prophylaxis - adult





Medical History
the patient has not visited a dentist or received fluoride treatments in the past four years while away at college

SDT 176440D Patient referral

CDT D0150 comprehensive oral evaluation - new or established patient

Omit: 68071007 | Dental fluoride treatment (procedure) | - use a negationInd?

MedicationRequest (status=active); Medication

Medication.code

MedicationRequest.dosageInstruction

erythromycin 500 mg, Take 1 tablet every six hours X10 days

ibuprofen (OTC)  200 mg tab, Take 2-3 tablets every 8 hours as needed for pain

acetaminophen (OTC) 325 mg, Take 2 tablets every 4-6 hours as needed for pain

RxNorm

315877 - Erythromycin 500 mg tab

316074 - Ibuprofen 200 mg tab

315253- Acetaminophen 325 mg tab


Organization

Organization.name
Good Oral Health Clinic

Patient

Patient.us-core-ethnicity (extension)

Patient.name

Patient.gender


us-core-race & ethnicity

Hispanic or Latino (2135-2 OmbEthnicityCategories)

White (2106-3 OmbRaceCategories)

AdministrativeGender- male

Practitioner

Practitioner.identifier:NPI

Practitioner.name

Practitioner Organization

103-456-7384

Dr. D

Good Oral Health Clinic


PractitionerRole

PractitionerRole.code

PractitionerRole.specialty


Healthcare Provider Taxonomy (HIPAA)

122300000X Dental Providers; Dentist

Provider Role (HL7)

RT - Referred to Provider


Procedure

Procedure.code

Fluoride Treatment

extraction of the left lower molar (tooth #18) (D7250?)

restoration on the right upper lateral incisor (tooth #7) (D2331)

CDT D1206 topical application of fluoride varnish

CDT D7140 extraction, erupted tooth or exposed root (elevation and/or forceps removal)

SDT 161372D Entire permanent mandibular left second molar tooth (body structure); Tooth number 18


CDT D2331 resin-based composite - two surfaces, anterior 

SCT 245574002 Entire permanent maxillary right lateral incisor tooth (body structure); Tooth number 7


Social History

College Education

Full-time employee:  accountant

224302000 | Received higher education college education (finding)
106302007 | Accountant (occupation) |

Reason for Referral (status=planned)

Encounter.reasonReference

Encounter.priority

Dental Consult, priority - urgent

SDT 198872D Dental consultation and report

SDT 212086D Urgent referral

SCT 34043003 Dental consultation and report


RiskAssessment

RiskAssessment.condition

RiskAssessment.basis (reference Questionnaire/Response)

RiskAssessment.prediction.qualitativeRisk

Perio risk assessment

Caries risk assessment

**TODO: do risk assessments get updated and sent back to medical?**

SDT 179051D At high risk for dental caries (finding)

SCT 609402003 At high risk for dental caries (finding)

ICD Z91.843 Risk for dental caries, high

Vital Signs Observation 

Observation.component.value

Temp:

Pulse:

Respirations:

BP:

LOINC

8310-5 Body Temperature

8867-4 Heart rate

9279-1 Respiratory Rate

8642-4 Diastolic BP

8480-6 Systolic BP

Value set:  Vital Sign Result Type urn:oid:2.16.840.1.113883.3.88.12.80.62

Success Criteria

For Medical systems: Medical Record (EHR) system able to GET bundle (consult note) above from test (HAPI) server

For Dental systems: Dental record system successfully generates and POSTS above bundle to test (HAPI) server

Bonus point

Medical record system able to parse bundle entries and successfully store entry data



Scenario 3: Dental to Dental (Endodontist) Referral

Chief Complaint:  Patient A is a 24 yo reports to Dentist D pain on lower RQ. 

History of Present Illness:  Patient A said the pain started 2 weeks ago and has progressively worsened. He noticed sharp, stabbing pain provoked by drinking cold beverages in the past week and lingering pain with biting in the last 2 days.  He is able to eat regular food but only chews on the left side.  He takes 400 mg ibuprofen every 8 hours for pain.  His last doses was 2 hours prior to this visit.

Medical History:    Patient A has a history of hypertension and is taking Lisinopril 10 mg tablet once daily.  Patient is also on erythromycin 500 mg every six hours for the infection and taking ibuprofen and acetaminophen as needed for pain .

Allergies:  Patient is allergic to penicillin.

Dental History: One month ago, pt. reports he had a MOBD amalgam restoration (D2161 #30 MOBD) placed in his right lower first molar (tooth #30) for a fractured tooth - MB cusp lost due to undermining by caries lesion (ADA Caries Classification System advanced caries lesion).

Vital Signs: BP 130/86, Pulse = 92

Assessment:

Intraoral findings:  On exam of the right lower quadrant, tooth #30 was sensitive to percussion (lingering for 45 seconds) and to cold (sharp, stops when cold removed). No sensitivity to palpation, pain upon biting with relief upon opening. No evidence of new caries on distal; missing #28, replaced with endosteal (root form) implant with full crown tooth-colored restoration; #32 impacted with possible full boney impaction. One cm swelling present on buccal gingivae around #29 and #30 with sinus tract present #30B. 

Paraoral findings: 2 small, mobile lymph nodes found in right submandibular area.

Test performed:  Electric pulp test was positive for vitality #29 and 31 with #30 non-responsive.  Cold test responsive #30, lingering 15 sec.

Radiographic/Imaging: Two PA x-rays (URL to access?) (D0220 #29 area, D0230, #30 area)) of the affected teeth (29, 30, 31) were exposed in the office today. Panoramic radiograph (D0330) exposed. Radiographic results showed #32 full bony impaction, #28 endosteal (root form) implant with full crown restoration, and tooth #30 with small PA lesion mesial root. Radiographic caries lesion #29 distal caries lesion (ADA Caries Classification System moderate caries lesion). Other WNL

Primary Diagnosis:

  • #30 pulpal necrosis and periapical pathosis with draining fistula
  • Clinical impression is that possible vital pulp remnants remain

Secondary diagnosis

  • #30 possible cracked DB cusp; rule out cracked tooth. Clinical impression is that tooth is restorable.
  • #29 D caries lesion (ADA CCS moderate caries lesion)

Reason for Referral:

Referral to endodontist for evaluation of #30 and endodontic therapy #30.  Referral includes medications prescribed, diagnosis, prognosis, treatment notes, images, and follow up recommendations to be sent from Dentist to Endodontist

(Map to 1084: 5.17 Plan of Care)


Resource Type

*=confirmed for Connectathon

Data Element

Sample Data

Codes

AllergyIntollerance*


AllergyIntollerance.code

 Penicillin

RxNorm

7908 Penicillin G (Ingredient)

Chief Complaint
Pain on  lower RQ


SDT: 101315D Pain

SDT: 212076D Lower right quadrant of dental arch

Condition*

Condition.code

Condition.bodySite

Condition.verificationStatus

Condition.category

Restored Caries Lesion

Possible DB Cusp Fracture

Primary Diagnosis: periapical pathosis with draining fistula

Primary Diagnosis:

  • #30 pulpal necrosis and periapical pathosis with draining fistula
  • Clinical impression is that possible vital pulp remnants remain

Secondary diagnosis

  • #30 possible cracked DB cusp; rule out cracked tooth. Clinical impression is that tooth is restorable.
  • #29 D caries lesion (ADA CCS moderate caries lesion)

SDT 160770D Entire permanent mandibular right first molar tooth (body structure); tooth number 30

SCT 245592005 Entire permanent mandibular right first molar tooth (body structure); tooth number 30

SDT 125784D Irreversible pulpitis (disorder)

SCT 109600005 Irreversible pulpitis (disorder)

ICD K04.02 Irreversible pulpitis

SDT 210362D At risk of fracture of tooth (finding)

SCT 716363001 At risk of fracture of tooth (finding)

SDT 163124D Entire distobuccal cusp (body structure)

SCT 245724002 Entire distobuccal cusp (body structure)

SDT 121901D Periapical abscess with sinus tract

SCT 74598008 Periapical abscess with sinus tract

Dental History
One month ago, pt. reports he had a MOBD amalgam restoration (D2161 #30 MOBD) placed in his right lower first molar (tooth #30) for a fractured tooth - MB cusp lost due to undermining by caries lesion (ADA Caries Classification System advanced caries lesion).

Encounter (planned)*

Encounter.status

Encounter.period


Encounter (with Dentist M) for pain on lower RQ

Endodontist appointment

**Need encounter code **

History of Present Illness
Patient A said the pain started 2 weeks ago and has progressively worsened. He noticed sharp, stabbing pain provoked by drinking cold beverages in the past week and lingering pain with biting in the last 2 days. He is able to eat regular food but only chews on the left side. He takes 400 mg ibuprofen every 8 hours for pain. His last doses was 2 hours prior to this visit.

 ImagingStudy*

ImagingStudy.status

ImagingStudy.subject

DICOM images:

Two PA x-rays (URL to access?) (D0220 #29 area, D0230, #30 area)) of the affected teeth (29, 30, 31) were exposed in the office today. Panoramic radiograph (D0330) exposed.

Findings: Radiographic results showed #32 full bony impaction, #28 endosteal (root form) implant with full crown restoration, and tooth #30 with small PA lesion mesial root. Radiographic caries lesion #29 distal caries lesion (ADA Caries Classification System moderate caries lesion). Other WNL

CDT D0220 (29, 30) D0230 (30, 31)

CDT D0330 Panoramic Radiograph 

SDT 160770D Entire permanent mandibular right first molar tooth (body structure); tooth number 30

LOINC 18782-3 Radiology Study Observation (narrative)


SCT 245592005 Entire permanent mandibular right first molar tooth (body structure); tooth number 30

SDT 125784D Irreversible pulpitis (disorder)

SCT 109600005 Irreversible pulpitis (disorder)

ICD K04.02 Irreversible pulpitis


Medical History

The patient has not visited a dentist or received fluoride treatments in the past four years while away at college


Mild, Hypertension

(outcome of RiskAssessment should be included as a Condition)

Tobacco Hx here as with Scenatrio 1?

SDT 212092D Patient asked to make an appointment

CDT D0150 comprehensive oral evaluation - new or established patient

D0150 referral (same as Scenario 1)

Omit:

Use Procedure.status="not-done" or omit

SDT 175027D Hypertensive disorder (disorder)

SCT 38341003 Hypertensive disorder (disorder)

ICD I10 Essential (primary) hypertension

MedicationRequest & Medication 

Medication.code

MedicationRequest.dosageInstruction

Lisinopril 10 mg tab, taking 1 tab once a day

erythromycin 500 mg, Take 1 tablet every six hours X10 days

 ibuprofen (OTC) 200 mg tab, Take 2-3 tablets every 8 hours as needed for pain

acetaminophen (OTC) 325 mg, Take 2 tablets every 4-6 hours as needed for pain

 RxNorm -

314076 Lisinopril 10 mg Oral Tablet

315877 - Erythromycin 500 mg tab

316074 - Ibuprofen 200 mg tab

315253- Acetaminophen 325 mg tab

 

Observation

Observation.code

Observation.value

Dental Clinical Findings: 165877D

Intraoral findings:  On exam of the right lower quadrant, tooth #30 was sensitive to percussion (lingering for 45 seconds) and to cold (sharp, stops when cold removed). No sensitivity to palpation, pain upon biting with relief upon opening. No evidence of new caries on distal; missing #28, replaced with endosteal (root form) implant with full crown tooth-colored restoration; #32 impacted with possible full boney impaction. One cm swelling present on buccal gingivae around #29 and #30 with sinus tract present #30B. 

Paraoral findings: 2 small, mobile lymph nodes found in right submandibular area.

Test performed:  Electric pulp test was positive for vitality #29 and 31 with #30 non-responsive.  Cold test responsive #30, lingering 15 sec.


SDT 165877D Dental Clinical Findings; CDT D0140 - limited oral evaluation - problem focused

CDT D0460 Pulp viability test result value: #30 -

SDT 128058D Tooth tender to percussion; 

SDT 108969D Tooth sensitivity to cold  

SDT 149233D No evidence of  SDT 101857D Tooth sensitivity to palpation

SDT 106172D Tooth sensitivity to pressure 

SDT 149233D No evidence of SDT 132634D Secondary dental caries SDT 146014D Distal surface of tooth #30;

#28 - SDT 100203D Tooth missing; CDT D6010 Surgical placement of implant body: endosteal implant;

SDT 178492D Dental crown present; 

#32 - SDT 130542D Completely impacted tooth in bone

SDT 127861D - Observation of appearance of gingivae; SDT 212078D - Localized swelling; SDT 109364D - Buccal mucosa; #29 and #30; #30 -SDT 109364D Buccal mucosa SDT 109579D Fistulous tract. 

SDT 212080D - On examination - lymph nodes fluctuant;  SDT 169943D - Right side; SDT 172296D submandibular area

Patient*

Patient.us-core-race (extension)

Patient.us-core-ethnicity (extension)



Practitioner*

Practitioner.identifier:NPI

Practitioner.name



PractitionerRole*

PractitionerRole.code



Procedure*

 

Procedure.code

Procedure.outcome

MOBD amalgam restoration noted (in odontogram). 

CDT D2161 amalgam - four or more surfaces, primary or permanent

SDT 121901D Periapical abscess with sinus tract

SCT 74598008 Periapical abscess with sinus tract

SDT 160770D Entire permanent mandibular right first molar tooth (body structure); tooth number 30

SCT 245592005 Entire permanent mandibular right first molar tooth (body structure); tooth number 30

Referral Note (CCDAonFHIR) Reason for Referral

Composition.Reason for Referral Section


Referral to endodontist for evaluation of #30 and endodontic therapy.  (D3330)

Suspect irreversible pulpitis with necrotic pulp and periapical pathosis. Tooth is restorable despite possible incomplete fracture DB cusp #30.

SDT 176809D Referral to endodontic service:

CDT D3330 - endodontic therapy, molar tooth (excluding final restoration)

SCT 431183005 Referral to endodontic service

 

SDT 160770D Entire permanent mandibular right first molar tooth (body structure); tooth number 30

SCT 245592005 Entire permanent mandibular right first molar tooth (body structure); tooth number 30

ServiceRequest*


ServiceRequest.status

ServiceRequest.category

ServiceRequest.code


Endodontist Referral for for evaluation of #30 and endodontic therapy #30

.category=planned

.code=



SDT 176809D Referral to endodontic service

SCT 431183005 Referral to endodontic service


Vital Signs Observation*

Observation.component.value

BP 130/86, Pulse 92

LOINC

85353-1 Vital Signs Panel

9279-1 Respiratory Rate

 8867-4 Heart rate

 8642-4 Diastolic BP

8480-6 Systolic BP

85354-9 Blood Pressure panel (systolic and diastolic)

2708-6 O2 Saturation

8310-5 Body Temp

8302-2 Body Height

9843-4 Head Circumference

29463-7 Body Weight

39156-5 Body Mass Index

Value set:  Vital Sign Result Type urn:oid:2.16.840.1.113883.3.88.12.80.62

Note- see optional observation codes associated with above codes here:

http://hl7.org/fhir/R4/valueset-observation-vitalsignresult.html

Success Criteria

For Dental systems: Record system able to successfully generate and POST bundle (referral note) above to test (HAPI) server

For Dental systems: Record system able to GET bundle (referral note) above from test (HAPI) server

Bonus point

Dental record system able to parse received bundle entries and successfully store entry data



Scenario 4: Dental (Endodontist) to Dental (General Dentist) Referral Result

Reason for Consult:  Referral to endodontist for evaluation of #30 and endodontic therapy.  

Referring Dx: Suspect irreversible pulpitis tooth #30 with necrotic pulp and periapical pathosis with draining fistula. Tooth is restorable despite possible incomplete fracture DB cusp #30.

Chief Complaint:  Patient A is a 24 yo reports to Endodontist upon referral with pain lower RQ, points to #30. 

History of Present Illness:  Patient A said the pain started 2 weeks ago and has progressively worsened. He noticed sharp, stabbing pain provoked by drinking cold beverages in the past week and lingering pain with biting in the last 2 days.  He is able to eat regular food but only chews on the left side.  He takes 400 mg ibuprofen every 8 hours for pain.  His last doses was 2 hours prior to this visit. He visited his general dentist and was referred to Endodontist.

Dental and Medical History, Allergies: See above as example, which was verified by Endodontist. (Previous Dental History from referring dentistOne month ago, pt. reports he had a MOBD amalgam restoration (D2161 #30 MOBD) placed in his right lower first molar (tooth #30) for a fractured tooth - MB cusp lost due to undermining by caries lesion (ADA Caries Classification System advanced caries lesion (Previous Medical History and Allergies from referring dentist: Medical History: Patient A has a history of hypertension and is taking Lisinopril 10 mg tablet once daily. Patient is also on erythromycin 500 mg every six hours for the infection and taking ibuprofen and acetaminophen as needed for pain. Allergies:  Patient is allergic to penicillin).

Exam: Endodontist confirmed above (exam code D0140 or D0160?). (from referring dentist: Intraoral findings:  On exam of the right lower quadrant, tooth #30 was sensitive to percussion (lingering for 45 seconds) and to cold (sharp, stops when cold removed). No sensitivity to palpation, pain upon biting with relief upon opening. No evidence of new caries on distal; missing #28, replaced with endosteal (root form) implant with full crown tooth-colored restoration; #32 impacted with possible full boney impaction. One cm swelling present on buccal gingivae around #29 and #30 with sinus tract present #30B. Paraoral findings: 2 small, mobile lymph nodes found in right submandibular area.)

Also performed transillumination and dye tests (blue dye) within pulp chamber during endodontic therapy and saw no evidence of cracks. Exposed one diagnostic periapical radiograph (charge D0220?) and confirmed radiographic findings above.

Vital Signs: BP 120/80, Pulse = 90

Procedures:  Endodontic therapy tooth #30 (D3330) with local anesthesia, gutta percha fill with sealer. (Dx: Irreversible pulpitis #30 with necrotic pulp with PAP mesial root accompanied by draining sinus tract on B.) No vertical fracture of root apparent during endodontic therapy (disorder). One preop PA and two postop PA radiographs exposed as part of endodontic treatment were returned with consult (referral) report to referring general dentist. Rx: Tylenol #3, 12 tabs, 1 or 2 q4-6 hrs prn pain. 

Prognosis: Good. Recommend restoration with full crown.  Note: Puff of sealer noted around M root; monitor for the next year, and, if sealer does not resorb, consider apicoectomy.

Radiographs: Images from endodontist (one pretreatment periapical and two postop periapical images of final fill) sent to referring general dentist. (and acquired via DART system?)

***Question: Did Endo wrist script for Tylenol?*** Yes- Tylenol #3, 12 tabs, 1 or 2 q 4-6 hours prn pain - see above.

A dental consult (referral) note is generated including medications prescribed, diagnosis, prognosis, treatment notes, images, and follow up recommendations and sent from the Endodontist to the General Dentist.


Resource Type

Data Element


Codes

Condition

Condition.verficiationStatus

Condition.category

Condition.code

Irreversible pulpitis #30


Referring Dx: Suspect irreversible pulpitis tooth #30 with necrotic pulp and periapical pathosis with draining fistula. Tooth is restorable despite possible incomplete fracture DB cusp #30.

SDT 125784D Irreversible pulpitis (disorder)

SCT 109600005 Irreversible pulpitis (disorder)

ICD K04.02 Irreversible pulpitis

SDT 160770D Entire permanent mandibular right first molar tooth (body structure); tooth number 30

SCT 245592005 Entire permanent mandibular right first molar tooth (body structure); tooth number 30

Encounter

Encounter.status

Encounter.period

March 15, 2020 follow up with Endodontist

April 1, 2020 follow up with Dentist


Reason for Consult:
Referral to endodontist for evaluation of #30 and endodontic therapy.
Dental History
see above

 ImagingStudy*

ImagingStudy.status

ImagingStudy.subject

acquired images

new images showing completed endodontic therapy (final film) (possibly multiple)

CDT/SNODENT/SCT

CDT D0230 intraoral - periapical each additional radiographic image (Should only a D0220 for #30 be charged because PAs are included with endo? Should any images be charged vs. recording they were exposed?)

SDT 207187D Previously initiated endodontic therapy completed

SCT 718392007 Previously initiated endodontic therapy completed

MedicationRequest & Medication 

Medication.code

MedicationRequest.dosageInstruction

Acetaminophen 300 MG / Codeine Phosphate 30 MG. Take 1 tablet every 4 hours as needed for pain.  Dispense #10 tablets.

RxNorm

993836 = Acetaminophen 300 MG / Codeine Phosphate 30 MG [Tylenol with Codeine]

Observation

Observation.code

Observation.value[x]

Observation.bodySite

Observation.method

(Intraoral findings)

(Paraoral findings)


Exam: Endodontist confirmed above (exam code D0140 or D0160?).

Tests:  Also performed transillumination and dye tests (blue dye) within pulp chamber during endodontic therapy and saw no evidence of cracks. Exposed one diagnostic periapical radiograph (charge D0220?) and confirmed radiographic findings above 


Radiographs: Images from endodontist (one pretreatment periapical and two periapical images of final fill) sent and acquired via DART system

SDT 125784D Irreversible pulpitis (disorder)

SCT 109600005 Irreversible pulpitis (disorder)

ICD K04.02 Irreversible pulpitis

Procedure

Procedure.code

Procedure.outcome

Endodontic therapy #30


 Endodontic therapy tooth #30 (D3330). (Dx: Irreversible pulpitis #30 with necrotic pulp with PAP mesial root accompanied by draining sinus tract on B.) No vertical fracture of root apparent during endodontic therapy (disorder).

CDT D3330 endodontic therapy, molar tooth (excluding final restoration)

Prognosis
Prognosis: Good. Recommend restoration with full crown.  Note: Puff of sealer noted around M root; monitor for the next year, and, if sealer does not resorb, consider apicoectomy.
ServiceRequest*

ServiceRequest.category

ServiceRequest.code


Endodontist Referral for evaluation of #30 and endodontic therapy #30



SDT 176809D Referral to endodontic service

SCT 431183005 Referral to endodontic service


Success Criteria

For Dental systems: Record system able to successfully generate and POST bundle (consult note) above to test (HAPI) server

For Dental systems: Record system able to GET bundle (consult note) above from test (HAPI) server

Bonus point

Dental record system able to parse received bundle entries and successfully store entry data



TestScript(s)

NA

Security and Privacy Considerations

NA



Reasons for Referral Valueset - 3/30 HOMEWORK: Please add rows and column data as possible for review

Reason for ReferralSNODENT IDSNODENT DescriptionSNOMED IDSNOMED DescriptionICD CodeICD Term
Tooth pain131687DToothache27355003ToothacheK08.89Other specified disorders of teeth and supporting structures
Sore gums104458DSore gums11114002Sore gumsK06.8Other specified disorders of gingiva and edentulous alveolar ridge

Swollen gums

Bleeding gums

148393D

142683D

Swollen gums 

Bleeding gums

309685001

86276007

Swollen gums 

Bleeding gums

K06.8

K06.8

Other specified disorders of gingiva and edentulous alveolar ridge

Dental decay (dental caries disease)118065DDental caries 80967001Dental caries K02.9Dental caries, unspecified
Dental clearance prior to transplant, surgery, or other treatment cancer146328DCompliance with suggested dental care110475006Compliance with suggested dental careZ09Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
Trauma128117DDental trauma397869004Dental traumaT79.9XXAUnspecified early complication of trauma, initial encounter
Evaluate a swelling or other lesion, including infection and rule out oral cancer 128015DSwelling65124004SwellingK06.8Other specified disorders of gingiva and edentulous alveolar ridge
Oral lesion180678DOral lesion1071000119107Oral lesionK06.8Other specified disorders of gingiva and edentulous alveolar ridge
TMD pain167337DTemporomandibular joint painful on movement298376001Temporomandibular joint painful on movementM26.69Other specified disorders of temporomandibular joint
Tooth abnormalities, such as excessive erosion (eating disorder) or excessive wear of teeth135988DErosion of teeth82212003Erosion of teethK03.2Erosion of teeth
Erosion of teeth due to persistent vomiting104212DErosion of teeth due to persistent vomiting52031007Erosion of teeth due to persistent vomitingK03.2Erosion of teeth
Dry mouth138508DXerostomia87715008XerostomiaR68.2Dry mouth, unspecified
Lack of oral hygiene, including build-up of deposits on teeth140234DPoor oral hygiene110299009Poor oral hygiene

Accretions on teeth (deposits)127701DAccretions on teeth6288001Accretion on teethK03.6Deposits [accretions] on teeth
Abscess123286DAbscess128477000AbscessK12.2Cellulitis and abscess of mouth
Infection138169DDisorder due to infection40733004Disorder due to infectionB99.9Unspecified infectious disease
Diabetes133643DDiabetes mellitus73211009Diabetes mellitusE13.9Other specified diabetes mellitus without complications
Pregnancy174950DPregnant77386006PregnantZ33.1Pregnant state, incidental
Establish a Dental Home

D0150 (CDT)


Referral for comprehensive oral examination 
103697008

Patient referral for dental care (procedure)

Z02.9

Encounter for Administrative exam, unspecified

 
Disturbances in tooth eruption144684DDisturbance of tooth eruption or exfoliation234972003Disturbance of tooth eruption or exfoliationK00.6Disturbances in tooth eruption
Malocclusion 150365DMalocclusion of teeth47944004Malocclusion of teethM26.4Malocclusion, unspecified