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Instructions:

Insert the following section into the Terminology page

Overview

License Requirements

Implementers and testers of this specification SHALL abide by the license requirements for each terminology content artifact utilized within a functioning implementation. Terminology licenses SHALL be obtained from the terminology authority for each code system or other specified artifact used. It is the sole responsibility of each organization deploying or testing this specification to ensure their implementations comply with licensing requirements.

Unless the licensors provide FHIR friendly Code System URIs, the coded content in profiles cannot be validated out-of-the-box.

 

Industry Standard Codes – Licenses Required  

Notes

  • AMA CPT:  The CPT procedure and modifier codes are owned by the American Medical Association. CARIN Alliance can write implementation guides which require the use of CPT, however implementers will need to obtain a license from the AMA.  HL7 does not have a license to publish the CPT codes. 
  • X12:  CARC Codes are owned by X12.  HL7 does not have a current or pending agreement with X12 to publish example codes. 
  • NUBC:  The CMS website URLs provided for the UB04 codes are a 2007 transmittal from the initial implementation of the UB-04. Pointing to CMS might create a copyright issue with CMS as it references the National Uniform Billing Committee (NUBC); the NUBC link is www.nubc.org .  As HL7 does not have a license to publish the NUBC code sets, the CARIN Alliance may not be able to publish NUBC code sets to those who don’t have a contract with them.  However, since CARIN BB supports Medicare members, possibly using the CMS URL would be permitted.  The NUBC secretariat is the American Hospital Association.  HL7 is in discussions with NUBC on a draft SOU that would allow HL7 to use example codes
  • SNOMED:  It is not recommended that SNOMED CT codes be used as they are not used by payers.  An exception may be made if the Code System definition applies to clinical and payer data.  Should SNOMED codes be used, they may require a license
  • NCPDP:  Retail Pharmacy data standards are defined by NCPDP (National Council for Prescription Drug Programs, (NCPDP). Use of NCPDP codes requires a license.  (Note that NDC codes are not owned by NCPDP).  Pointing to CMS site ResDAC might create a copyright issue with CMS as it references NCPDP codes.  HL7 does not have a license to publish the NCPDP code sets.  However, since CARIN BB supports Medicare members, possibly using the CMS ResDAC URL would be permitted.  HL7 has in place general SOU with NCPDP though it doesn’t deal with use of codes.  They are in discussions about updates to the SOU.   

 

Industry Standard Codes – License Not Required

Notes

  • ICD-Diagnosis (ICD_CM) Codes: International Statistical Classification of Diseases and Related Health Problems (ICD).  The ICD-10-CM code set is maintained by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC) for use in the United States. It is based on ICD-10, which was developed by the World Health Organization (WHO) and is used internationally a medical classification.
  • ICD-Procedure Codes (ICD-PCS):  The ICD-10-PCS code set is owned by CMS and is available for use
  • DRG:   All versions of the DRG (MS-DRG, AP-DRG, etc.) are o wned by CMS and are available for use.
  • HCPCS Level II Procedure Codes:  Primarily include non-physician products, supplies, and procedures not included in CPT.  They are owned by CMS and are available for use.
  • HCPCS Procedure Modifier Code s:  Included in the HCPCS documentation
  • NDC (National Drug Codes):  The US Federal Drug Administration (FDA) Data Standards Council assigns the first 5 digits of the 11 digit code.  They are available for use
  • RARC Codes:  Owned by CMS and are available for use

 

Value Set and Code System Updates

Instructions

Below are Value Set and Code System updates.  They replace all ‘CARIN BB’ Value Set and Code Systems presently defined in the IG. Reference:  https://build.fhir.org/ig/HL7/carin-bb/terminology.html

There are 4 columns:

1)       The 1 st column identifies the current Value Set / Code System if defined in the draft IG.  Map IDs refer to the Mapping spreadsheet used to map the CARIN BB CPCDS (Common Payer Consumer Data Set) to FHIR.

2)       The 2 nd column defines the content of the data element.  It should be added to the IG as Value Sets are defined

3)       The 3 rd column defines the new Value Sets and Code Systems to be added to the IG

4)       The 4 th column are working notes and are not to be added to the IG. 

 

A.   Licensed Value Sets

Industry Code Systems Requiring Licenses

NUBC – Inpatient and Outpatient Facility

Define the following for the Inpatient Facility and Outpatient Facility Profiles.  Do not define for Professional and Non-Clinician or Pharmacy

Current CARIN BB

Value Set

(if defined)

Definition

 

Update the following Value Sets and Code Systems with items highlighted in red           

Comment

1.  CARIN Blue Button Admit Source Value Set

Industry Standard Code

MapID: 13

 

UB-04 Point of Origin for Admission or Visit (FL-15)

 

Value Set:

http://hl7.org/fhir/us/ValueSet/nubc-pointoforiginforadmissionorvisit.html

Code System: 

 

NUBC codes are owned, maintained and distributed by the National Uniform Billing Committee (NUBC).  Use of NUBC codes require licenses.  The NUBC link is www.nubc.org

 

define the following uri:

http//www.nubc.org/point-of-origin-for-admission-or-visit

HL7 OID Registry: nubc-AdmissionSource-cs urn:oid:2.16.840.1.113883.6.301.4

  • The correct title is “Point of Origin for Admission or Visit” (it was formerly the Source of Admission).   The Excel mapping worksheet was updated to reflect the standard name.

      Amol / Lisa / Pat reviewed

 

2.  CARIN Blue Button Admit Type Value Set

Industry Standard Code

MapID: 14

UB-04 Priority (Type) of Admission or Visit (FL-14)

Value Set:

http://hl7.org/fhir/us/ValueSet/nubc-prioritytypeofadmissionorvisit.html

Code System:

NUBC codes are owned, maintained and distributed by the National Uniform Billing Committee (NUBC).  Use of NUBC codes require licenses.  The NUBC link is www.nubc.org

 

define the following uri:

http//www.nubc.org/priority-type-of-admission-or-visit

  • The correct title is “Priority (Type) of Admission or Visit.  The Excel mapping document was updated to reflect the standard name.
  • Amol – Lisa – Pat reviewed

Current CARIN BB

Value Set

(if defined)

Definition

 

Add the following Value Sets and Code Systems            

  • Comment

3. CARIN Blue Button Type Of Bill (Bill Classification) Value Set

Industry Standard Code

MapID: 115

 

UB-04 Type of Bill (FL-4)

 

Value Set:

http://hl7.org/fhir/us/ValueSet/nubc-typeofbill.html

Code System:

NUBC codes are owned, maintained and distributed by the National Uniform Billing Committee (NUBC).  Use of NUBC codes require licenses.  The NUBC link is www.nubc.org

 

define the following uri:

http//www.nubc.org/type-of-bill

HL7 OID Registry: nubc-TypeOfBill-cs

urn:oid: 2.16.840.1.113883.6.301.1

  • Type of Bill (Form Locater 04) is a 4 digit code.  As of UB-04, the first three positions should not be parsed apart, as they have no value independently, only as three digits (currently always a zero in the first digit).  The last digit is the frequency.  Many systems drop the leading zero and treat Type of Bill as a 3 digit code.  

 

      Amol – Lisa – Pat reviewed

4.  CARIN Blue Button Revenue Center Value Set

Industry Standard

MapID: 86

UB-04 Revenue Code UB-04 (FL-42)

Value Set:

http://hl7.org/fhir/us/ValueSet/nubc-revenuecode.html

Code System:

NUBC codes are owned, maintained and distributed by the National Uniform Billing Committee (NUBC).  Use of NUBC codes require licenses.  The NUBC link is www.nubc.org

 

use the following uri:

http//www.nubc.org/revenue-code

from the HL7 OID Registry: nubc-ServiceLineRevenue-cs urn:oid: 2.16.840.1.113883.6.301.3

  • The name is Revenue Code not Revenue Center

        Amol – Lisa – Pat reviewed

 

5.  CARIN Blue Button Discharge Status Value Set

Industry Standard Code

MapID: 117

 

UB-04 Patient Discharge Status (FL-17)

Value Set:

http://hl7.org/fhir/us/ValueSet/nubc-patientdischargestatus.html

Code System:

NUBC codes are owned, maintained and distributed by the National Uniform Billing Committee (NUBC).  Use of NUBC codes require licenses.  The NUBC link is www.nubc.org

 

Define the following uri:

http//www.nubc.org/patient-discharge

HL7 OID Registry: nubc-patDiscStatus-cs

urn:oid: 2.16.840.1.113883.6.301.5

 

  • Correct Title is “Patient Discharge Status” The Excel mapping document was updated to reflect the standard name.
  • C-CDA Code System urn:oid:2.16.840.1.113883.6.301.5
  • Amol – Lisa – Pat reviewed

NUBC – Inpatient Facility

Define the following for the Inpatient Facility Profile.  Do not define for Outpatient Facility, Professional and Non-Clinician or Pharmacy Profiles

Current CARIN BB

Value Set

(if defined)

Definition

 

Update the following Value Sets and Code Systems with items highlighted in red           

Comment

6. Present on Admission

Industry Standard Code

MapID: 28, 29

UB-04 Present on Admission

Value Set:

http://hl7.org/fhir/us/ValueSet/nubc-presentonadmission.html

Code System:

NUBC codes are owned, maintained and distributed by the National Uniform Billing Committee (NUBC).  Use of NUBC codes require licenses.  The NUBC link is www.nubc.org

 

Define the following uri:

http//www.nubc.org/present-on-admission

HL7 OID Registry: nubc-PresentOnAdmission-csurn:oid: 2.16.840.1.113883.6.301.11

 

NCPDP

Define the following for the Pharmacy EOB profile:  Do not define for any other profile

Current CARIN BB

Value Set

(if defined)

Definition

 

Add the following Value Sets and Code Systems            

Comment

7. NCPDP DAW product selection code (DAW)

 

Industry Standard Code

MapID: 79

Prescriber's instruction regarding substitution of generic equivalents or order to dispense the specific prescribed medication. NCPDP field # 408-D8 (Dispensed As Written

(DAW)/Product Selection Code)

Value Set:

 

Define an identifier as http://hl7.org/fhir/us/ValueSet/ncpcp-dispensedaswrittenorproductselectioncode.html

 

Code System:

 

Retail Pharmacy data standards are defined by NCPDP (National Council for Prescription Drug Programs, (NCPDP). Use of NCPDP codes requires a license. 

 

define the following uri:

http//www.ncpdp.org/dispensed-as-written-or-product-selection-code

 

Request HL7 define an OID named ncpdp-DispensedasWrittenOrProductSelectionCode-cs.

 

8. Prescription Origin Code

 

Industry Standard code

MapID: 143

Whether the prescription was transmitted as an electronic prescription, by phone, by fax, or as a written paper copy

Value Set:

 

Define an identifier as http://hl7.org/fhir/us/ValueSet/ncpdp-prescriptionorigincode.html

 

Code System:

Retail Pharmacy data standards are defined by NCPDP (National Council for Prescription Drug Programs, (NCPDP). Use of NCPDP codes requires a license. 

 

define the following uri:  http//www.ncpdp.org/prescription-origin-code

 

Request HL7 define an OID named ncpdp-PrescriptionOriginCode-cs.

 

9. Plan reported brand-generic code

 

Industry Standard code

MapID: 144

Whether the plan adjudicated the claim as a brand or generic drug

Value Set:

 

RESDAC shows the name of the data element as Brand-Generic Code Reported by Submitting Plan.  Will need to confirm once HL7 establishes an agreement with NCPDP

 

Code System:

Additional research is required to determine if the data element is one defined by NCPDP.

 

 

B.  Combination Value Sets

The following are a combination of Industry Code Systems that require licenses and those that don’t require licenses. 

CPT and HCPCS Value Sets, Code Systems

Define CPT and HCPCS Value Sets for the Inpatient Facility, Outpatient Facility and Professional and Non-Clinician Profiles.  Do not define for Pharmacy.

Current CARIN BB

Value Set

(if defined)

Definition

 

Add the following Value Sets and Code Systems            

Comment

10. CARIN Blue Button CPT/HCPCS Procedure Codes Value Set

Industry Standard Code

MapID: 40

 

Add:  CPT (HCPCS I) and HCPCS II Procedure Codes

Add a Comment:  This Value Set is a combination of two Code Systems:  CPT (HCPCS I) and HCPCS II procedure codes (HCPCS Codes are from the ANWEB file.  Using the short descriptions (instead of the long descriptions) for the textual representation is recommended.

Value Set:

Define a Value Set that groups together all values from CPT and the HCPCS procedure codes.

The identifier is http://hl7.org/fhir/us/ValueSet/AMA-CPT-CMS-HCPCS-procedure-codes.html

Code Systems:

1)       HCPCS Level I (CPT)

CPT codes are owned, maintained and distributed by the American Medical Association (AMA).  Use of the CPT codes requires a license.

 

http://www.ama-assn.org/go/cpt , where the codes are contained in http://hl7.org/fhir/ValueSet/cpt-all.html

HL7 OID Registry: cpt-4

urn:oid: 2.16.840.1.113883.6.12

2)       HCPCS Level II

The code set is owned by CMS and is available for use.

https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html

The link takes one to a list of files.  The HCPCS ANWEB files include modifier and procedure codes.    The target set for this Code System is the procedure codes from this file. 

HL7 OID Registry: hcpcs-Level-II

urn:oid: 2.16.840.1.113883.6.285

Recommend US Core assign an URL, http://www.cms.gov/hcpcs-level-II-procedure-codes

       Amol – Lisa – Pat reviewed                      

 

 

11.  CARIN Blue Button HCPCS Modifier Codes Value Set

Industry Standard Code

MapID: 41

 

 

Value Set:

Define a Value Set that groups together all modifier values from CPT and HCPCS modifiers from the ANWEB file: http://hl7.org/fhir/us/ValueSet/AMA-CPT-CMS-HCPCS-procedure-code-modifiers.html

 

Code Systems:

1)       HCPCS Level I (CPT)

CPT codes are owned, maintained and distributed by the American Medical Association (AMA).  Use of the CPT codes requires a license.

 

define the following uri: http://www.ama-assn.org/go/cpt-modifiers

Request HL7 to define an OID named CPT Procedure Code Modifiers.

2)       HCPCS Level II

The code set is owned by CMS and is available for use.

https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html

The link takes one to a list of files.  The HCPCS ANWEB files include modifier and procedure codes.   The target set for this Code System is the procedure code modifiers from this file. 

Request US Core define the following uri: http://www.cms.gov/hcpcs-level-II-modifiers

        Amol – Lisa – Pat reviewed

 

X12 and CMS

Define the following for all EOB profiles:  Inpatient Facility, Outpatient Facility Profile, Professional and Non-Clinician and Pharmacy

Current CARIN BB

Value Set

(if defined)

Definition

 

Add the following Value Sets and Code Systems            

Comment

12.  CARIN Blue Button Adjudication Denial Reason Value Set

Industry Standard Codes MapID: 92

 

Add a description:

Denial Reasons - Reason codes used to interpret the adjudication denial reason

Value Set:

Define a Value Set that groups together all values from CARC and RARC procedure codes:

http://hl7.org/fhir/us/ValueSet/ X12-CARC–CMS-RARC .html

Code System:

1)       Claim Adjustment Reason Codes (CARC):

CARC codes are owned, maintained and distributed by X12.  Use of X12 codes require licenses. 

Code system URL is http://www.x12.org/codes/claim-adjustment-reason-codes/  

2)       Remittance Advice Remark Codes (RARC):

RARC codes are owned by CMS and are available for use. 

http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes

Recommend US Core define http://www.wpc-edi.com/remittance-advice-remark

 

Amol / Lisa / Pat reviewed

 

C.  Non-Licensed Value Sets

The following are Industry Standard Code Systems that do not require licenses. 

NDC

Define the following for the Pharmacy EOB profile:  Do not define for any other profile.

Current CARIN BB

Value Set

(if defined)

Definition

 

Add the following Value Sets and Code Systems            

Comment

13. FDA NDC

 

Industry Standard Code

MapID: 38

National Drug Code (NDC) NCPDP field # 407-D7

Value Set:

http://hl7.org/fhir/us/ValueSet/fda-ndc.html

Code System:

The US Federal Drug Administration (FDA) Data Standards Council assigns the first 5 digits of the 11 digit code.  The NDC codes are available for use

http://hl7.org/fhir/sid/ndc.html

HL7 OID Registry: ndc

urn:oid:2.16.840.1.113883.6.69

 

 

DRG

Define the following for the Inpatient Facility EOB profile:  Do not define for any other profile.

Current CARIN BB

Value Set

(if defined)

Definition

 

Add the following Value Sets and Code Systems            

Comment

14.  CARIN Blue Button MS-DRG Value Set

Industry Standard Code

MapID: 33

 

Diagnosis Related Group - any of the payment categories that are used to classify patients and especially Medicare patients for the purpose of reimbursing hospitals for each case in a given category with a fixed fee regardless of the actual costs incurred.

Add comment:

Other DRGs, such as AP-DRGs, would each require a Value Set and Code System to be defined.

Value Set:

http://hl7.org/fhir/us/ValueSet/cms-ms-drg .html

Code System:

The code set is owned by CMS and is available for use.

define the following uri:

http//www.cms.gov/ms-drg

This link takes one to a list of files which cannot be used as a code system

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/MS-DRG-Classifications-and-Software.html

Request HL7 to define an OID named cms-ms-drg-cs.

Amol – Lisa – Pat reviewed

 

Place of Service

Define the following for the Professional & Non-Clinician EOB profile:  Do not define for any other profile

Current CARIN BB

Value Set

(if defined)

Definition

 

Add the following Value Sets and Code Systems            

Comment

15.  CARIN Blue Button Place Of Service Codes For Professional Claims Value Set

Industry Standard Code

MapID: 46

 

Place of Service - Codes placed on health care professional claims to indicate the setting in which a service was provided

Value Set:

http://hl7.org/fhir/us/ValueSet/cms-placeofservice.html

Code System:

The code set is owned by CMS and is available for use.

https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html

The link takes one to the Place of Service list as an html document; it is a file to which an IG can be bound.

Request HL7 define an OID named cms-place-of-service-cs.

 

       Updated the Excel mapping document to reflect removal from scope for Inpatient Facility and Outpatient Facility

        Amol – Lisa – Pat reviewed

 

 

ICD - CM

Define the following for the Inpatient Facility, Outpatient Facility and Professional & Non-Clinician EOB profiles:  Do not define for the Pharmacy profile.

Current CARIN BB

Value Set

(if defined)

Definition

 

Add the following Value Sets and Code Systems            

Comment

16. Diagnosis Code

Industry Standard Code

MapID: 21, 22, 23

ICD-10-CM code describing the condition chiefly responsible for a patient's admission to a facility. It may be different from the principal diagnosis, which is the diagnosis assigned after evaluation. Decimals will be included.

Value Set:

http://hl7.org/fhir/us/ValueSet/cdc-icd-10-cm-diagnosiscodes.html

 

Code System:

The Consumer-Directed Payer Data Exchange will use ICD-CM version 10.  The ICD-10-CM code set is maintained by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC) for use in the United States. It is based on ICD-10, which was developed by the World Health Organization (WHO) and is used internationally a medical classification.

The code set is owned by the NCHS-CDC and is available for use.  https://www.icd10data.com/ICD10CM/Codes

provides the actual codes but not as a list against which validation could be performed

 

Reference https://www.hl7.org/fhir/icd.html .

 

US variant is http://hl7.org/fhir/sid/icd-10-cm .  It receives a -404

HL7 OID Registry: icd10CM

urn:oid:2.16.840.1.113883.6.90

  • Neither US Core, Argonaut nor C-CDA define a Value Set / Code System for ICD-10-CM diagnosis codes

 

ICD - PCS

Define the following for the Inpatient Facility profile:  Do not define for any other Profiles.

Current CARIN BB

Value Set

(if defined)

Definition

 

Add the following Value Sets and Code Systems            

Comment

17. ICD-10 PCS Procedure Codes

Industry Code Set

MapID: 24, 26

 

ICD-10-PCS Procedure Codes

Principal medical procedure a patient received during an inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10).

Value Set:

http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-icd10pcs

Code System: 

The Consumer-Directed Payer Data Exchange will use ICD-PCS version 10.  The ICD-10-PCS code set is maintained by CMS.  The code set is owned by CMS and is available for use.

 

The ICD-10-PCS website defined in the US Core Code System, https://www.icd10data.com/ICD10PCS provides a link to the codes but not as a table against which binding could occur.

  • Payers receive ICD-10-PCS procedure codes for institutional inpatient claims. Payers do not receive SNOMED codes on claims.
  • Replace with the ICD-10-PCS code set
  • Argonaut uses the same Value Set and Code Set

       Amol – Lisa – Pat reviewed

 

 

 

D.  HL7 Value Sets

The following are HL7 Value Sets used by this IG. 

EOB Profiles

Define the following for all EOB profiles:  Inpatient Facility, Outpatient Facility Profile, Professional and Non-Clinician and Pharmacy

CARIN BB data element

CARIN Definition

Source

Comment

18. Claim Type

HL7 Code

MapID: 16                 

Specifies the type of claim. (e.g., inpatient institutional, outpatient institutional, physician, etc.).

Add a comment:

Within the context of the CARIN BB IG the concept of ‘institutional’ and the concept ‘facility’ are considered to be synonyms. 

Value Set:

http://www.hl7.org/fhir/valueset-claim-type.html

It is an extensible codeable concept.

Code System:

http://www.hl7.org/fhir/codesystem-claim-type.html

Current values are institutional | oral | pharmacy | professional | vision. 

Request FM update the values and definitions.  A separate ballot feedback line item was submitted.  See Appendix – HL7 Requests – Claim Type Updates

      Amol – Lisa – Pat reviewed. 

19. Related Claim Relationship Codes

HL7 Code

MapID:  New (111, 112)

Defines how the reference claim is related

Value Set:

Use the HL7 example value set:  https://www.hl7.org/fhir/valueset-related-claim-relationship.html  

Code System:

HL7 Code System, https://www.hl7.org/fhir/codesystem-related-claim-relationship.html , defines the values: prior | associated.  CARIN defines prior | replaced by.  Request FM add a new value.  A separate ballot feedback line item was submitted. 

 

 

Patient Profile

Define the following on the Patient Profile:

CARIN BB data element

CARIN Definition

Source

Comment

20. Gender

HL7 Code Set

MapID: 71

The gender of the member

Value Set:

https://www.hl7.org/fhir/valueset-administrative-gender.html

Code System:

https://www.hl7.org/fhir/codesystem-administrative-gender.html  

  • Do not see Value Sets for US Core nor Argonaut

21. Birth sex

HL7 Code Set

MapID: 153

The gender of the member at birth

Value Set:

Value Set:  http://hl7.org/fhir/us/core/ValueSet-birthsex.html

Code System:

Use the Code System defined for this Value Set.

This Value Set uses codes from two Code Systems: one Code System has codes from the AdministrativeGender Value Set and the other comes from the HL7 Null Flavor.   

 

  • The Value Set from Argonaut is specific to Argonaut.

https://www.fhir.org/guides/argonaut/r2/ValueSet-usrealm-birthsex.html CARIN BB will use the FHIR Value Set and Code System

      Amol – Lisa – Pat reviewed

22.  Race

Industry Standard Code

MapID: 128

The race of the member

 

Add a comment:

App developers need to be aware that Patient Race is carried in an extension allowing for up to five values per patient. 

Value Set:

Use the CDC at http://hl7.org/fhir/us/core/ValueSet/detailed-race

Code System:

This Value Set uses codes recommended by the Center for Disease Control (CDC) defined in urn:oid:2.16.840.1.113883.6.238, http://hl7.org/fhir/us/core/CodeSystem-cdcrec.html    

The U.S. Centers for Disease Control and Prevention (CDC) has prepared a code set for use in coding race and ethnicity data

        Amol – Lisa – Pat reviewed

        Based on BCBSA SME feedback, Pat changed to use the CDC Value Set.  It uses the same Code System as Ethnicity

Use the OMB Race Categories at  https://build.fhir.org/ig/HL7/US-Core-R4/ValueSet-omb-race-category.html

         

23.  Ethnicity

Industry Standard Code

MapID: 129

The ethnicity of the member

 

Add a comment:

App developers need to be aware that Patient Ethnicity is carried in an extension

Value Set:

Use the US Core https://build.fhir.org/ig/HL7/US-Core-R4/ValueSet-detailed-ethnicity.html

Code System:

This Value Set uses codes recommended by the Center for Disease Control (CDC) defined in urn:oid:2.16.840.1.113883.6.238, http://hl7.org/fhir/us/core/CodeSystem-cdcrec.html    

The U.S. Centers for Disease Control and Prevention (CDC) has prepared a code set for use in coding race and ethnicity data

        Amol – Lisa – Pat reviewed

        Based on BCBSA SME feedback, used value set from US Core rather than OMB. 

OMB Race Categories at  http://hl7.org/fhir/us/core/ValueSet-omb-ethnicity-category.html

         

 

Coverage Profile

Define the following on the Coverage Profile:

CARIN BB data element

CARIN Definition

Source

Comment

24. Relationship to subscriber

HL7 Code

MapID: 72

Relationship of the member to the person insured (subscriber)

Value Set

Recommend Value Set:  https://www.hl7.org/fhir/valueset-subscriber-relationship.html

Code System:

https://www.hl7.org/fhir/codesystem-subscriber-relationship.html

 

 

E.  New Value Sets and Code Systems

The following are Non-Industry Value Sets and Standard Code Systems used by payers.

New Code Systems require an HL7 harmonization proposal to request creation of the Code Systems.  The HL7 Workgroup is the UTG (Unified Terminology Governance)

Adjudication Category

Define the following for all EOB profiles:  Inpatient Facility, Outpatient Facility Profile, Professional and Non-Clinician and Pharmacy

Current CARIN BB

Value Set

(if defined)

Definition

Add the following Value Sets and Code Systems                         

Comment

25. Amounts

Non-industry Code

MapID: 20, new(20)

Adjudication Amount Category describes the various amount fields used when payers receive and adjudicate a claim

Value Set:

 

http://hl7.org/fhir/us/ValueSet/payer-adjudicationamountcategory.html

where values include the following codes from the Code System: submitted | allowed | deductible |coins | copay | noncovered | priorpayerpaid | payment | paidbypatient | paidtoprovider | paidtopatient | memberliability | discount | drugcost

 

Code System:

 

define the following:

http://hl7.org/fhir/us/CodeSystem/payer-adjudication-category

where values are submitted | allowed | deductible |coins | copay | noncovered | priorpayerpaid | payment | paidbypatient | paidtoprovider | paidtopatient | memberliability | discount | drugcost | in-network | out-of-network | other | contracted | non-contracted |subscriber | provider | other | paid | denied

 

The Code System is also used in the following Value Sets:

#26 - Benefit Payment Status Category

#27 - Provider Network Status

#28 - Claim Payee Type Code

#29 - Claim Payment Status Code

 

Previously was CARIN Blue Button Adjudication Amount Category Value Set

Amol / Lisa / Pat reviewed

26. Benefit payment status

Non-industry Code

MapID: 142

Indicates the in network or out of network payment status of the claim.

Value Set:

http://hl7.org/fhir/us/ValueSet/payer-benefitpaymentstatus.html where values include the following codes from the Code System:  in-network | out-of-network | other

Code System:

The Code System is https://build.fhir.org/ig/HL7/payer/CodeSystem-adjudication-category.htm the same Code System defined in Value Set #25, Adjudication Amount Category

Previously was CARIN Blue Button Adjudication Benefit Payment Status Category Value Set

Amol / Lisa / Pat reviewed

 

27. Provider Network Status

Non-industry Code

MapID: 101

Indicates that the Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission.

Value Set:

http://hl7.org/fhir/us/ValueSet/payer-providernetworkstatus.html where values include the following codes from the Code System:  contracted | non-contracted

 

Code System:

https://build.fhir.org/ig/HL7/payer/CodeSystem-adjudication-category.htm the same Code System defined in Value Set #25, Adjudication Amount Category

 

28. Claim Payee Type Code

 

Non-industry Code

MapID: 120

Identifies recipient of benefits payable; i.e., provider or subscriber

Value Set

http://hl7.org/fhir/us/ValueSet/payer-payeetypecode.html where values include the following codes from the Code System:  subscriber | provider | other

 

Code System:

The Code System is the same Code System defined in Value Set #25, Adjudication Amount Category

 

29. Claim Payment Status Code

 

Non-industry Code

MapID: 91

Indicates whether the claim / item was paid or denied.

Value Set

http://hl7.org/fhir/us/ValueSet/payer-paymentstatuscode.html where values include the following codes from the Code System:  paid | denied

 

Code System:

The Code System is the same Code System defined in Value Set #25, Adjudication Amount Category

 

 

Diagnosis Type

 

Define for the Inpatient Facility and Outpatient Facility profiles:  Do not define for Professional and Non-Clinician and Pharmacy

Current CARIN BB

Value Set

(if defined)

Definition

Add the following Value Sets and Code Systems                         

Comment

30.  Diagnosis Type - Facility

Non-industry standard Code MapID: 21, 22, 23

Indicates if the facility diagnosis is principal, secondary, an external cause of injury, a patient reason for visit, or first-listed

Value Set:

http://hl7.org/fhir/us/ValueSet/payer-facilitydiagnosistype.html where values include the following codes from the Code System:  admitting | principal | secondary | external cause of injury | patient reason for visit | first-listed

Code System:

define the following:

http://hl7.org/fhir/us/CodeSystem/payer-diagnosis-type where values are: admitting | principal | secondary | external-cause-of-injury | patient-reason-for-visit | first-listed

 

  • Previous set of values were admitting | principal | secondary | external cause of injury | patient reason for visit.  Add first-listed (Pat to confirm with Amol and Lisa)
  • @Define the difference between primary vs principal vs admitting for diagnosis code and procedure codes (facility claims)
  • Amol – Lisa – Pat reviewed       

 

 

 

Define for the Professional and Non-Clinician Profiles.  Do not define for any other profile

Current CARIN BB

Value Set

(if defined)

Definition

Add the following Value Sets and Code Systems                         

Comment

31.  Diagnosis Type – Professional and Non-Clinican

Non-industry standard Code MapID: 21, 22, 23

Indicates if the professional and non-clinician diagnosis is principal, secondary, or first-listed

Value Set:

http://hl7.org/fhir/us/ValueSet/payer-professionalandnoncliniciandiagnosistype.html where values include the following codes from the Code System:  principal | secondary | first-listed. 

Code System:

https://build.fhir.org/ig/HL7/payer/CodeSystem-diagnosis-type.html the same Code System defined in Value Set #30, Facility Diagnosis Type

  • See comments in Diagnosis Type - Facility

 

 

Define for the Inpatient Facility profiles:  Do not define for any other profile

Current CARIN BB

Value Set

(if defined)

Definition

Add the following Value Sets and Code Systems                         

Comment

32. Present on Admission Type Code

Non-industry standard Code MapID: 28, 29

Indicates if the Present on Admission Code applies to the Primary or secondary diagnosis

Value Set:

http://hl7.org/fhir/us/ValueSet/payer-presentonadmissiondiagnosistype.html where values include the following codes from the Code System:  principal | secondary

Code System:

https://build.fhir.org/ig/HL7/payer/CodeSystem-diagnosis-type.html the same Code System defined in Value Set #30, Facility Diagnosis Type

  •  

 

Provider Role

The value set content differ depending on the EOB type. 

Current CARIN BB

Value Set

(if defined)

Definition

Add the following Value Sets and Code Systems                         

Comment

33. Provider Role

CARIN BB Code

MapID:

93, 95, 96, 99

Indicates the role of the provider providing the care

Value Sets:

Define an identifier on the Inpatient Facility profile to be http://hl7.org/fhir/us/ValueSet/payer-inpatientfacilityproviderrole.html with the following values from the Code System:  attending | performing | pcp | referring

 

Define an identifier on the Outpatient Facility profile to be http://hl7.org/fhir/us/ValueSet/payer-outpatientfacilityproviderrole.html with the following values from the Code System:  performing | pcp | referring

 

Define an identifier on the Professional and Non-Clinician profile to be http://hl7.org/fhir/us/ValueSet/payer-professionalandnonclinicianproviderrole.html with the following values from the Code System:  performing | pcp | referring | site

 

Define an identifier on the Pharmacy profile to be http://hl7.org/fhir/us/ValueSet/payer-pharmacyproviderrole.html with the following values from the Code System: performing | pcp | prescribing

Code System:

define the following:

https://build.fhir.org/ig/HL7/payer/CodeSystem-provider-role.html where values are: attending | performing | pcp | referring | site | prescribing

 

  • US Core and Argonaut CareTeam Provider Roles Value Sets are not useable by CARIN BB.  The US Core / Argonaut Value Sets are similar to the specialty of the provider; i.e., they are   NUCC Health Care Provider Taxonomy Code Set for providers   and SNOMED -CT for non-clinical and organization roles including codes from the SCTID 125676002 Person (person) hierarchy and the SCTID 394730007 Healthcare related organization (qualifier value) hierarchy”

Appendix – HL7 Requests

The following have been submitted as ballot feedback

HL7 Financial Management (FM) Workgroup Requests

Requests will be entered as a series of ballot comments

  • #18:  Revise values of the Claim Type Code System (see Claim Type updates below)
  • #19:  The HL7 Code System, https://www.hl7.org/fhir/codesystem-related-claim-relationship.html, defines the values: prior | associated.  CARIN BB defines prior | replaced by.  May the value ‘replaced by’ be added? 
  • Several data elements were added as .supportinginfo as they were not defined in FHIR V4.  How do we propose they are considered to be included in FHIR v5?
  • OIDs were included if they are defined.  Should new OIDs be requested if they’re not defined? 
  • There are a few new Value Sets and Code Systems.  New Code Systems require an HL7 harmonization proposal to request creation of the Code Systems.  The HL7 Workgroup is the UTG (Unified Terminology Governance)

Claim Type updates

The present Value Set and Code System values for Claim Type are the following http://hl7.org/fhir/ValueSet/claim-type

cid:image003.jpg@01D5D2B9.A8BEFFD0

 

The Institutional definition speaks to ‘typically inpatient claims’.   In our experience, institutional claims typically include inpatient and outpatient claims.   Due to differences in applicable code sets (for example, DRGs and ICD Procedure Codes are relevant only for Inpatient Facility claims), the IG defines two institutional profiles, one for inpatient and one for outpatient.   We recommend defining two Claim Type values for institutional claims.  

                         

Code

Display

Definition

institutional - inpatient

Institutional - Inpatient

Claims submitted by clinics, hospitals, skilled nursing facilities, and other institutions for inpatient services, including the use of equipment and supplies, laboratory services, radiology services, and other charges.   Inpatient claims are submitted for admissions for which there is an overnight stay. The claims data is based on submission standards adopted by the Department of Health and Human Services (CMS-1450).

institutional - outpatient

Institutional - Outpatient

Claims submitted by clinics, hospitals, skilled nursing facilities, and other institutions for outpatient services, including the use of equipment and supplies, laboratory services, radiology services, and other charges.   Outpatient claims are submitted for admissions for which there is not an overnight stay. The claims data is based on submission standards adopted by the Department of Health and Human Services (CMS-1450).

 

The Professional definition speaks to ‘outpatient claims from a Physician’ but doesn’t speak to inpatient claims from a physician.     The codes don’t speak to the non-clinician suppliers, such as DME, Home Health Care, Ambulance, etc.   We recommend modifying the code, display and description as follows:

 

Code

Display

Definition

professional-nonclinician

Professional and Non-Clinician

Claims submitted by physicians, suppliers, and other non-institutional providers for inpatient, outpatient and non-institutional services.   The claims data is based on submission standards adopted by the Department of Health and Human Services (CMS-1500).   Claims with CPT (Current Procedural Terminology) codes represent physician services and claims with Level II HCPCS codes represent non-physician services like ambulance rides, wheelchairs, walkers, other durable medical equipment, and other medical services that are not identified by CPT/HCPCS Level I codes.

 

Pharmacy data is typically provided by retail pharmacies.   Specialty drugs are typically provided by physicians.   To convey that these claims are submitted by retail pharmacies, our recommendation is to modify the code, display and definition pharmacy as follows:

 

Code

Display

Definition

retail pharmacy

Retail Pharmacy

Claims submitted by retail pharmacies.   The claims data is based on submission standards adopted by the Department of Health and Human   Services defined by NCPDP (National Council for Prescription Drug Program)

 

Oral and pharmacy definitions remain unchanged. 

Appendix

Findings:  CARIN BB – Argonaut – C-CDA – US Core

Analysis performed against US Core Profiles (i.e., US Core Procedure) considers alignment with US-CDI v1 (US Core Data for Interoperability).  The FHIR US Core IG was developed to represent all data elements in the US CDI v1. 

Findings

  • C-CDA comparison to Blue Button Value Sets and Code Systems for Procedures :  C-CDA Procedure Activity Procedure entry template recommends (SHOULD) Coded Concepts from LOINC or SNOMED CT and allows (MAY) concepts from CPT-4, ICD-10PCS, or CDT-2 (dental).  Therefore, it can’t be used by Blue Button as payer data does not use LOINC or SNOMED CT. 
  • Argonaut comparison to Blue Button Value Sets and Code Systems for Procedures :  Argonaut defines a combination of CPT and SNOMED codes.  Therefore, it can’t be used by Blue Button as payer data does not use SNOMED CT.  Additionally Blue Button requires HCPCS II Codes which Argonaut does not define.  Below is the Argonaut link:  http://fhir.org/guides/argonaut/ValueSet/procedure-type ; includes all codes defined in http://www.ama-assn.org/go/cpt and http://snomed.info/sct where concept is-a 71388002 (Procedure).
  • US Core comparison to Blue Button Value Sets and Code System for CPT and HCPCS Procedures :   US Core Procedure Codes use an extensible binding that references an “example” value set. This example value set defines a set of codes that can be used to indicate the type of procedure: a specific code indicating type of procedure performed, from CPT, SNOMED CT, or HCPCS Level II Alphanumeric Codes.  This value set includes codes from CPT and SNOMED CT defined from the following Code Systems: Include all codes defined in http://www.ama-assn.org/go/cpt , Include codes from http://snomed.info/sct where concept is-a 71388002 (Procedure), Include all codes defined in urn:oid:2.16.840.1.113883.6.285 (HCPCS II Codes).  Therefore, it can’t be used by Blue Button as payer data does not use SNOMED CT. 
  • US Core comparison to Blue Button Value Sets and Code System for ICD PCS Procedures:  The ICD-10 procedure codes are in the US Core Implementation Guide (v3.1.0: STU3 Update).  CARIN Blue Button will use US Core
  • Race | Birth Sex | Ethnicity:   The CARIN BB IG does not define Value Sets for Race, Birth Sex or Ethnicity.  Recommend to align with specifications from U.S. Core Patient Profile.  This also aligns with value set guidance in C-CDA.  
  • Diagnosis Codes :  Argonaut nor C-CDA defines a Value Set / Code System for ICD-10-CM diagnosis codes.  US Core defines an Externally Published code systems http://hl7.org/fhir/R4/icd.html#4.2.11
  • Care Team:   US Core and Argonaut CareTeam Provider Roles Value Sets are not useable by CARIN BB.  The values for Blue Button are attending | performing | pcp | referring | site | prescribing.  The US Core / Argonaut Value Sets are similar to the specialty of the provider; i.e., they consist of NUCC Health Care Provider Taxonomy Code Set for providers and SNOMED-CT for non-clinical and organization roles including codes from the SCTID 125676002 Person (person) hierarchy and the SCTID 394730007 Healthcare related organization (qualifier value) hierarchy
  • Patient Discharge Status: C-CDA ValueSet name: NUBC UB-04 FL17 Patient Status. C-CDA ValueSet oid: 2.16.840.1.113883.3.88.12.80.33.  This value set is not available in the C-CDA expansion package (i.e., could not download).  In C-CDA this value set is used in the header of a Discharge Summary Document for this data element: componentOf/encompassingEncounter/dischargeDispositionCode