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Data Categories

(Payer-required data elements)

Domain

(cover sheet vs. medical record)

USCDI v1

USCDI v2 Draft

Level 2 (likely addition to v2)

Level 1 (future addition)

Comment (new submission)

US Core

Code System

Follow-Ups

Patient Demographics


Patient *

First Name
First NamePatient.name.given

Last Name
Last NamePatient.name.family

Previous Name
Previous NamePatient.name.given
Patient.name.period


Middle Name (including middle initial)
Middle Name (including middle initial)


Suffix
SuffixPatient.name.suffix

* Birth Sex
Birth SexPatient.extension:birthsexHL7 V3 for administrative genderWait for Gender Identity Project White Paper with codesets
https://confluence.hl7.org/display/VOC/The+Gender+Harmony+Project
* Gender Identity
Gender IdentityPatient.gender
Wait for Gender Identity Project White Paper with codesets
* Sex for Clinical Use



Wait for Gender Identity Project White Paper with codesets
* Recorded Sex




Date of Birth
Date of BirthPatient.birthDate

Race
RacePatient.extension:raceOMB
CDC standard sets
Is this used for prior auth adjudication?
Ethnicity
EthnicityPatient.extension:ethnicityOMB
CDC standard sets
Is this used for prior auth adjudication?
Preferred Language
Preferred LanguagePatient.communication.language
Patient.communication.preffered
RFC 5646Is this used for prior auth adjudication?
Current Address
Current AddressPatient.address

Previous Address



Not used for prior auth
Phone Number


ITU E.123
ITU E.164
Not used for prior auth
Phone Number Type



Not used for prior auth
Email Address



Not used for prior auth
* Coverage ID
Policy NumberPatient.identifier

* Subscriber vs. Patient

Payer Identifier

Subscriber Identifier



How to call out

Location of Service


Location of ProcedureOrganization *
Location *
Patient.managingOrganization
Encounter.location

What do payers require?
Provider

Practitioner *
PractitionerRoles *

Which providers are needed for a prior auth?
PCP Name
Provider NamePatient.generalPractitioner
Practitioner.name


PCP Role
Provider RolePractitionerRole

PCP NPI
Provider NPIPractitioner.identifier:NPI
Is prior auth accepted from non-healthcare providers?
PCP Certification

Practitioner.qualification







Ordering Provider Name
Provider NameEncounter.participant *
Procedure.performer *
Procedure.asserter *


Ordering Provider Role
Provider Role


Case Worker










Rendering Provider Name
Provider NameEncounter.participant *
Procedure.performer *
Procedure.asserter *


Rendering Provider Role
Provider Role


Care Team Member(s)


Care Team MembersCareTeam* ?

Care Team Member Name
Care Team MembersCareTeam.name

Care Team Member Role
Provider RoleCareTeam.participant.role

Period Active

CareTeam.period

Medications

MedicationsMedicationDispense (?)
Medication *
MedicationRequest *
Medication Statement (?)


Medication Name
Medications

Medication.text

MedicationRequest.text



Dose

Dosage

Medication Administration Dose

Medication Administration Dose Units

Medication Prescribed Dose

Medication Prescribed Dose Units

MedicationRequest.dosageInstruction.doseAndRate

Route of administration
Medication Administration

MedicationRequest.dosageInstruction.site

MedicationRequest.dosageInstruction.route



Frequency

MedicationRequest.dosageInstruction.timing

MedicationRequest.dosageInstruction.doseAndRate



Start Date

Date Medication Administered

Date Medication Prescribed

MedicationRequest.authoredOn

End Date




Medication Status (active/inactive)

Medication.status



Allergies and Intolerances

AllergyIntolerance

Substance (Drug Class)
Substance (Drug Class)

AllergyIntolerance.text

AllergyIntolerance.category

SNOMED-CT
Substance (Medication)
Substance (Medication)

AllergyIntolerance.text

AllergyIntolerance.category

RxNorm
Reaction
ReactionAllergyIntolerance.reactionSNOMED-CT
Substance (Food)
Substance (Food)

AllergyIntolerance.text

AllergyIntolerance.category



Substance (Non-Medication)
Substance (Non-Medication)

AllergyIntolerance.text

AllergyIntolerance.category



Health Concerns

Condition *

Health Concerns
Health Concerns
SNOMED-CT
ICD-10
Coding system included in USCDI Level 2
Problems

Condition *

Problems (includes diagnosis if available)

Problems (SNOMED)

Problems (SNOMED & ICD-10)

Condition.codeSNOMED CT
FHIR US CORE Condition.code example bound to SNOMED CT, so ICD is also conformant
Comment in support of both ICD-10 & SNOMED

Start Date


Date of Onset

Date of Diagnosis

Condition.recordedDate

End Date
Date of Resolution


Problem Status

Condition.clinicalStatus

Immunizations

Immunization *
How are booster shots documented?
Immunization Name
ImmunizationsImmunization.vaccineCodeCDC IIS: Current HL7 Standard Code Set
CVX - Vaccines Administered
CDC National Drug Code Directory

Date Administered

Immunization Administered Date

Vaccination Administered Date




Unique Device Identifier(s)
      (Note: also needed for devices that do not have UDIs or for which they are not available)


Device *
DeviceRequest
DeviceDefinition

Are there any devices that don't have UDI? If so, how to document?
Unique Device Identifier(s) for a patient’s implantable device(s)
     [UDI as described by applicable FDA regulation]

Unique Device Identifiers for a patient's implantable devices

UDI-Device Identifier or UDI-DI

Device.identifier

Device Type

Device.deviceName.type

Device Description

Device.note

Date Performed




Production Identifier
UDI-Production Identifier-Serial or UDI-PI-Serial

Is this used for PA?
Assessment and Plan of Treatment

Observation *
Goal *
CarePlan *


Assessment and Plan of Treatment
Assessment and Plan of Treatment

Goal.note

Goal.description

CarePlan.description



Linked Order

Goal.addresses

CarePlan.addresses


Talk to EHRs - is this something that can sent across in messages today?
Start Date

Goal.start

CarePlan.created



Plan Type

Goal.category

CarePlan.category



Clinical Notes

DocumentReference *
DiagnosticReport *


Note Type

Consultation Note

Discarge Summary Note

History & Physical

Imaging Narrative

Laboratory Report Narrative

Pathology Report Narrative

Procedure Note

Progress Note

DocumentReference.type

DiagnosticReport.category

LOINC
Note Body

Consultation Note

Discarge Summary Note

History & Physical

Imaging Narrative

Laboratory Report Narrative

Pathology Report Narrative

Procedure Note

Progress Note

DocumentReference.content

DiagnosticReport.conclusion



Date Recorded

DocumentReference.date

DiagnosticReport.issued



Note Author

DocumentReference.author

DocumentReference.authenticator



Note Author Credentials




Related Encounter

DocumentReference.context

DiagnosticReport.encounter



Procedures

Procedure *

Date/Time Ordered




Date/Time Performed
Procedure TimingProcedure.performed

Procedure Code

Procedure.codeHCPCS
CPT
SNOMED-CT
ICD-10 (optional)
CDT (optional – for dental procedures)

Ordering Provider




Performing Provider/Clinician

Procedure.performed

Status
Procedure StatusProcedure.status

Vital Signs

Observation

VitalSigns



Diastolic BP
Diastolic blood pressure

Blood pressure systolic and diastolic

Diastolic blood pressure

LOINC
UCUM

Systolic BP
Systolic blood pressure

Blood pressure systolic and diastolic

Systolic blood pressure

LOINC
UCUM

Height
Body heightBody heightLOINC
UCUM

Weight
Body weightBody weightLOINC
UCUM

Heart rate
Heart RateHeart rateLOINC
UCUM

Respiratory rate
Respiratory RateRespiratory RateLOINC
UCUM

Temperature
Body temperatureBody temperatureLOINC
UCUM

Pulse oximetry
Pulse oximetry
LOINC
UCUM

Inhaled oxygen concentration
Inhaled oxygen concentrationOxygen saturationLOINC
UCUM

BMI

BMI percentile (2-20 years)

BMI

Body mass indexLOINC
UCUM

Weight for length (Birth-36mo)
Weight-for-length Percentile (Birth-36 months)
LOINC
UCUM

Head Occipital frontal Circumference (Birth-36mo)
Head Occipital-frontal Circumference Percentile (Birth-36 Months)
LOINC
UCUM

Date/Time Recorded
Vital sign results: date and timestamps


Laboratory

Observation *
DiagnosticReport *


Tests
TestsObservation.codeLOINC
UCUM

Values

Values

Laboratory Result Value

Observation.value

Observation.note

UCUM

SNOMED


Date/Time Resulted

Laboratory results: date and timestamps

Observation.issued

Date Performed
Laboratory Test Performed DateObservation.effective

Performer

Observation.performed

Organization

Organization *
Location *


Place of Service
Encounter Location

Organization.identifier:NPI

Organization.name



Submitting Organization (submitting the prior auth)

Organization.identifier:NPI

Organization.name


Review if this is required by anyone
Encounter

Encounter *

Date/Time
Encounter TimingEncounter.period

Encounter Type
Encounter TypeEncounter.type

Location (including Medium - video, in-person, etc)
Encounter LocationEncounter.location

Practitioner(s)

Encounter.participant

Payer Information

Coverage

Health Insurance Lvl 2 USCDI

Might need to list multiple payers

Coverage Type
Coverage Type


Coverage Period
Coverage Period


Group Number
Group Number


Policy Number
Policy Number


Payer Name
Payer Name


Member ID
Member ID


Subscriber ID
Subscriber ID


Payer ID
Payer ID


Discrete structured and coded observations

Observation

Observation Date/Time

(includes lab test)






DME Order
DME Orders



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