CDAR1AIS0004R020
Additional Information Specification 0004:
Clinical Reports Attachment
(This specification replaces
Additional Information Message 0004:
Clinical Reports Attachment
September 1, 2002)
Release 2.0
Based on HL7 CDA Standard Release 1.0,
with supporting LOINC® Tables
CDA Draft #1
July 17, 2003
© Copyright 2000, 2001,2002, 2003
Health Level Seven, Inc.
Ann Arbor, MI
Table of Contents
1
INTRODUCTION ...............................................................................................................................................1
1.1
1.2
1.3
1.4
1.5
1.6
2
HL7 CLINICAL REPORTS IN CDA DOCUMENTS .....................................................................................4
2.1
2.2
2.3
3
LOINC CODES AND STRUCTURE ....................................................................................................................1
REVISION HISTORY .........................................................................................................................................2
PRIVACY CONCERNS IN EXAMPLES ................................................................................................................2
HL7 ATTACHMENT-CDA DOCUMENT VARIANTS ..........................................................................................2
REQUEST FOR INFORMATION VERSUS REQUEST FOR SERVICE ........................................................................3
STRUCTURE IN CLINICAL REPORTS.................................................................................................................3
LOINC REPORT SUBJECT IDENTIFIER CODES.................................................................................................4
LOINC REPORT PART IDENTIFIER CODES ......................................................................................................5
SIGNATURES. ..................................................................................................................................................5
LOINC CODES ...................................................................................................................................................5
3.1
LOINC REPORT SUBJECT IDENTIFIER CODES.................................................................................................5
3.2
SCOPE MODIFICATION CODES ...................................................................................................................... 10
3.3
REPORT STRUCTURES ................................................................................................................................... 10
3.3.1
General Report Structure ..................................................................................................................... 11
3.3.2
Specific Report Structure ..................................................................................................................... 11
3.3.3
Coding Example – General report format ............................................................................................ 12
4
VALUE TABLES FOR SPECIFIC REPORT STRUCTURES .................................................................... 17
4.1
CARDIAC DIAGNOSTIC STUDIES ................................................................................................................... 18
4.1.1
Cardiac Echo Study ............................................................................................................................. 18
4.1.2
EKG STUDY ...................................................................................................................................... 20
4.2
OBSTETRICAL STUDIES ................................................................................................................................. 22
4.2.1
OB Ultrasound Study ........................................................................................................................... 22
4.3
CLINICAL NOTES/REPORTS........................................................................................................................... 26
4.3.1
Physician Hospital Discharge Summary (HOSP DISCH) ................................................................... 26
4.3.2
Operative Note (OP NOTE)................................................................................................................. 27
4.3.3Provider Unspecified History and Physical Note ........................................................................................ 28
4.4
RADIOLOGY STUDIES ................................................................................................................................... 32
4.4.1
Cervical Spine X-Ray .......................................................................................................................... 32
4.4.2
CT Study Head .................................................................................................................................... 33
4.4.3
CT Study Extremity ............................................................................................................................. 33
4.4.4
MRI Study Head .................................................................................................................................. 34
4.4.5
Mammogram Screening Study ............................................................................................................ 34
4.4.6
Nuclear Medicine Bone Scan Study .................................................................................................... 35
4.4.7
CT Guidance for Aspiration Study, Unspecified Site .......................................................................... 35
4.4.8
Ultrasound Study of Neck .................................................................................................................... 36
5
RESPONSE CODE SETS ................................................................................................................................. 37
5.1
5.2
5.3
5.4
5.5
5.6
ANS+: EXTENDED ANSI UNITS CODES ......................................................................................................... 37
C4: CPT-4 .................................................................................................................................................... 37
HL70103: PROCESSING ID ........................................................................................................................... 37
I9C: ICD-9-CM ............................................................................................................................................ 37
ISO+: EXTENDED ISO UNITS CODES ............................................................................................................. 37
NPI: NATIONAL PROVIDER ID ...................................................................................................................... 37
Index of Tables and Figures
Table 1.1 Relationship of LOINC Codes, X12N Transactions, and HL7 CDA Document ............................................2
Table 3.1 - LOINC Report Subject Identifier Codes ......................................................................................................6
Table 3.3 - Specific/General vs Human/Computer-Decision Variant ......................................................................... 11
Figure 1. Hospital discharge summary, human-decision variant................................................................................ 15
Table 4.1.1 - Cardiac Echo Study ................................................................................................................................ 18
Table 4.1.2 - EKG STUDY........................................................................................................................................... 20
Table 4.2.1 - OB Ultrasound Study.............................................................................................................................. 22
Table 4.3.1 - Physician Hospital Discharge Summary ................................................................................................ 27
Table 4.3.2 - Operative Note ....................................................................................................................................... 27
Table 4.3.3 - Provider Unspecified History & Physical Note ..................................................................................... 29
Table 4.4.1 – Cervical Spine X-Ray............................................................................................................................. 32
Table 4.4.2 – CT Study Head ....................................................................................................................................... 33
Table 4.4.3 - CT Study Extremity ................................................................................................................................. 33
Table 4.4.4- MRI Study Head ...................................................................................................................................... 34
Table 4.4.5- Mammogram Screening Study ................................................................................................................. 34
Table 4.4.6- Nuclear Medicine Bone Scan Study ........................................................................................................ 35
Table 4.4.7 - CT Guidance for Aspiration Study, Unspecified Site ............................................................................. 35
Table 4.4.8- Ultrasound Study of Neck ........................................................................................................................ 36
Tables 3.1. and all of the tables in Section 4 are copyright,  1995-2003 Regenstrief Institute and the LOINC
Attachment Committee. All rights reserved.
Additional Information Specification 0004
Clinical Reports Attachment
HL7 Version 2.4 Standard, Release 1.0
with supporting LOINC® Tables
1 Introduction
This publication provides the LOINC1 code values specific to clinical reports attachments for the
following applications.
 Certain codes are to be used in transactions defined by the ASC X12N 277 Implementation
Guide (004050X104) Health Care Claim Request for Additional Information and the ASC
X12N 275 Implementation Guide (004050X107) Additional Information to Support a
Health Care Claim or Encounter which are products of the insurance subcommittee, X12N,
of Accredited Standards Committee X12.2,3
 All of the codes may be used in HL7 CDA documents designed for inclusion in the BIN
segment of the 275 transaction as described in HL7 Additional Information Specification
Implementation Guide4.
The format of this document and the methods used to arrive at its contents are prescribed in the
HL7 Implementation Guide. Section 2 of this document defines the CDA document variants used
for attachment data. Section 3 defines the LOINC codes used to request clinical reports
attachment data. Section 4 includes the value tables of LOINC codes specific to the data
elements of a clinical reports attachment. Section 3 presents a fully coded example additional info
to support clinical reports.
LOINC codes are copyright 1995-2003 Regenstrief Institute and the LOINC® Committee. All
rights reserved.
1.1
LOINC Codes and Structure
LOINC codes are used for several different purposes in the two X12 transactions and HL7
message that are used to request and provide clinical reports. The table below identifies four
specific uses of LOINC codes and describes their use within the messages.
1
LOINC® is a registered trademark of Regenstrief Institute and the LOINC Committee. The LOINC database and
LOINC Users’ Guide are copyright 1995-2003 Regenstrief Institute and the LOINC Committee and the LOINC
database codes and names are available at no-cost from http://www.regenstrief.org/loinc/. Regenstrief Institute,
1050 Wishard Blvd., Indianapolis, IN 46202, Email: LOINC@regenstrief.org
2
Information on this and other X12N/HIPAA-related implementation guides is available from the Washington
Publishing Company, Gaithersburg, MD. http://www.wpc-edi.com/
3
Within this Health Level Seven document, references to the transaction defined by these X12N implementation
guides will be abbreviated by calling them 275 and 277.
4
Health Level Seven, Inc. 3300 Washtenaw Ave., Suite 227, Ann Arbor, MI 48104-4250. (http://www.hl7.org)
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Table 1.1 Relationship of LOINC Codes, X12N Transactions, and HL7 CDA Document
1.2
X12N 277
X12N 275
CDA
Purpose of
Message
Request for additional
information to support a
health care claim
Additional information
to support a health care
claim or encounter
Provide structured
content for X12N 275
BIN segment
LOINC
Modifier
Codes
Used in the STC
segment to limit the time
frame or scope of the
request
Reiterated in the STC
segment
Not used
LOINC
Attachment
or Element
Codes
Used in the STC
segment to identify the
attachment or portion
thereof being requested
Reiterated in the STC
segment
Used to define the
attachment element
being addressed
LOINC
Answer Part
Codes
Not used
Not used
Used to define the value
component of the
attachment element
Revision History
Date
Sept 30, 1998
Oct 27, 1998
Nov 11, 1998
Aug 7, 2000
Oct 2000
May 2001
Dec 2001
May 2002
Sept 2002
July 2003
1.3
Purpose
Initial release as separate document.
Revision based on comments.
Revise title, citations, and format of tables.
Update contact information.
Clarification and technical revisions.
Version update, title change, concept clarification, and continuity edits
Revised title and date; reconciled HL7 ballot
responses.
Editing changes requested by the balloters
Revised LOINC e-mail address
CDA Draft
Privacy Concerns in Examples
The names of natural persons that appear in the examples of this book are intentionally fictional.
Any resemblance to actual natural persons, living or deceased, is purely coincidental.
1.4
HL7 Attachment-CDA Document Variants
As described in the HL7 Implementation Guide, there are two variants of a CDA document when
used as an attachment.
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 The human-decision variant is used solely for information that will be rendered for a person
to look at, in order to make a decision. HL7 provides a non-normative style sheet for this
purpose. There are two further alternatives within the human-decision variant.
 non_xml body: The information can be sent with a CDA header structured in XML,
along with an "non_xml body" that references scanned images of documents that contain
the submitted information
 xml body: the information can be sent as free text in XML elements that organize the
material into sections, paragaphs, tables and lists as described in the HL7 Additional
Information Specification Implementation Guide.
 The computer-decision variant has the same content as the human-decision variant, but
additional coded and structured information is included so that a computer could provide
decision support based on the document. Attachments in the computer-decision variant can
be rendered for human decisions using the same style sheet that HL7 provides for rendering
documents formatted according to the human-decision variant.
1.5
Request for Information versus Request for Service
This attachment book for clinical reports defines a “send-me-what-you-have” attachment. It asks
for a set of clinical reports that have been produced in the course of the care process. It is not
asking for any additional data capture efforts. For example, if the request for data is all chest xray reports, it is not asking the provider to obtain a chest x-ray report, but just to report any chest
x-ray reports that happen to have been done.
1.6
Structure in Clinical Reports
Clinical reports, by their nature, vary in the amount of structure represented in the human
readable version of the report. Some reports, such as electrocardiograms, present almost as much
structure and quantitative data as a laboratory test battery. For example, an EKG will usually
report the heart rate, the PR interval, and the QRS axis as discrete numerical results with units.
Dictated reports include varying amounts of structure, usually defined by sub headers in the
report. A radiology report for example will often contain headers for the reason for the study, the
comparison study dates and results, the description of the exam and the diagnostic impression.
The description may include one or two paragraphs, the impression be further divided by
numbered bullets that identify each separate diagnostic conclusion. At the least structured
extreme, some narrative reports contain no structure except for paragraphing.
HL7 CDA documents that represent clinical reports also vary in the degree to which they
represent the structure that exists in the clinical report. By the nature of the HL7 CDA, at least the
patient demographic information, the kind of report, the time of the report, and (usually) the
reporting provider will be delivered as structured, and computer understandable content. The
demographic information e.g., the patient chart number, name, birthdate, is carried as structured
information in CDA header.
As described in section 1.4, the clinical content of the report is in scanned images (humandecision variant, non-xml body), natural language text (human-decision variant, XML body) or,
where the data are available to support structure, as a structure amenable to interpretation by a
computer (computer-decision variant).
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It is likely that most clinical report attachments will tend to send the entire report as one of the
two options within the human-decision variant. The only requirements for reports passed using
this method are:
 the patient must be identified
 the report must be identified with a LOINC code
 an electronic report that contains structure information must contain the blocks of text
together in the sequence in which they appear in the print form of the report.
Over time, clinical report attachments with more structure will become more common. For payers
that intend to have a human make a decision based on the clinical report, it will be unimportant
whether the attachment is largely text or coded in detail in the computer-decision variant. In each
case an XML style sheet will support rendering the information for human usage.
2 HL7 Clinical Reports in CDA Documents
This section defines how to use CDA documents to pass clinical reports as attachments. Because very little is
assumed about the contents of the structured information, the approach described here can be used for reports about
a wide variety of functional topics. These include, but are not limited to, discharge summaries, operative notes,
history and physicals, clinic visits, other assessments, and all types of diagnostic procedures including radiology
reports, EKGs, cardiac echoes, and so on.
2.1
LOINC Report Subject Identifier Codes
Clinical reports can be classified by many different dimensions, e.g., the method used to generate
the data (e.g., CAT scan), the body part examined (x-ray of left wrist), the kinds of measurements
produced, e.g., blood pressure. Individual clinical reports are specified by indicating specific
values for many of these dimensions.
It would be very difficult to enumerate and isolate all combinations of these facets that represent
realistic subjects for all possible clinical reports. Indeed, such a task would never end, because
individual practices continue to refine their procedures to find combinations of measurements that
use improved methods, or have fewer side effects or are more economical.
At this time, the Regenstrief Institute and the LOINC Attachment Committee have chosen to
provide a set of subject identifier codes that are categorical for many subjects, i.e., a given code
can apply to closely related reports. The categories were chosen based on examinations of
existing requests for information in support of claims. They will add to this code set based on
industry requests. However for some reports and some subject matters, LOINC also provides the
option for very detailed and specific observation reporting.
Systems that initiate requests in 277 messages shall choose the LOINC Report Subject Identifier
Code corresponding to the category that best represents the subject matter of interest. Responding
systems shall echo the requester’s LOINC code in the 275 and report the LOINC Report Subject
Identifier Codes that most closely identify the delivered individual reports in the
<document_type_cd> element in the CDA header. For example, a payer may send a 277 that
requests a LOINC Report Subject Identifier Code of 26441-6, CARDIAC STUDIES (SET). In
the CDA payloads of the 275,the provider would then return reports for the available cardiac
studies e.g., EKG, Cardiac Echoes, Cardiac Catheterization, etc. that had been performed on the
patient and also satisfied the constraints of any LOINC modifier codes included in the 277. The
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responding 275 message might therefore include 18745-0 Cardiac Catheterization Heart Report
and 11524-6 EKG Heart Study.
When unsolicited attachments are sent in an X12 275 transaction that accompanies an 837, the
sender should pick the LOINC Report Subject Identifier Codes that most closely identifies the
report being sent.
Note: each CDA document can only hold a single report. Is it possible to send
multiple documents in a 275? If not we have to add a mechanism for
including multiple XML documents in a single BIN segment.
2.2
LOINC Report Part Identifier Codes
Each LOINC Report Part Identifier Code identifies a section of a report that will be sent a
<section> element of the XML body. There are no stated requirements for the sequence of the
LOINC Report Part Identifier Codes within the document except that the text blocks should be
presented to the the order in which they would appear in the report in the patient's chart.
2.3
Signatures.
Certain clinical reports include LOINC codes for the name and identifier of the signing
practitioner. This information shall be provided in the header of CDA attachments. It may also be
provided redundantly in the body with the appropriate LOINC codes.
3 LOINC Codes
3.1
LOINC Report Subject Identifier Codes
The provider shall return all requested data elements for which data is available. The minimum
attachment data set equates to the required elements; those identified in the value tables in
Section 4 with a cardinality (Card) of {1,1} (element is required and has one and only one
occurrence) or {1,n} (element is required and has one or more occurrences). Those data elements
with a cardinality of {0,1} (if available has one and only one occurrence) or {0,n} (if available
may have one or more occurrences) shall be sent if available. This seems superfluous or
out of place.
Requestors can use any LOINC code that is contained in the hierarchy of Clinical-Reports-nonlab (LOINC 26443-2) as the report subject identifier in a 277 request message. The full available
set can be easily reviewed through the HIPAA attachment task of RELMA, the LOINC browsing
tool. (Available at no cost from http://www.regenstrief.org/loinc/loinc.htm - send questions by
email to LOINC@regenstrief.org.) You can see all LOINC codes contained within Clinical
Reports.Non Lab via the HIPAA attachment task in RELMA.
Table 3.1 provides examples of the more common Clinical Reports request subject codes
described in Section 2.1. Note that this table defines a hierarchy. To request all “ClinicalReports-non-lab” use LOINC 26443-2 (the first row of Table 3.1) as the subject identifier in the
277 request message. To request a more narrow set of reports, use more specific codes further
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down the hierarchy. For example, if interested only in “Diagnostic-Studies-non-lab” use LOINC
27899-4 (see the second row of Table 3.1) in the 277 subject identifier. In that case, the 275
message would return only LOINC codes beneath 27899-4 namely all cardiology,
Gastroenterology, neuromuscular, obstetrics, pathology, radiology, pulmonary, ophthalmology,
optimology, and miscellaneous studies. By going further down the hierarchy you can narrow the
request further. For example, if interested only in radiology studies use Radiology Studies
(LOINC 18726-0) as the request subject identifies. If interested only in CT Head Study (LOINC
11539-4) use that individual code as the 277 request subject identifier.
Note that Table 3.1 does not include all possible report subject identifiers that are within the
scope of this attachment booklet. For example, many more specific Radiology diagnostic codes
exist within the LOINC database under the class of Radiology Studies (LOINC 18726-0) than are
included on pages 16 and 17 of this document. The full available set can be reviewed through the
HIPAA attachment task of RELMA, the LOINC browsing tool. Further, any of the more specific
LOINC codes that are listed beneath these codes (e.g., the left ventricular ejection fraction within
the cardiac echo report) are also valid individual subjects for the 277 report subject identifier.
(See Section 4.)
Each LOINC code beneath LOINC 26443-2 in the hierarchy is a valid subject identifier code for
277 messages. As the industry adds new diagnostic studies or clinical reports, new codes for these
studies/reports will be listed within this hierarchy and these codes will also be valid subject codes
for 277 requests.
Note also, that many reports may be delivered in a general or specific style as described in the
next section. If the 3rd column in table 3.1 contains the word “general” that means that LOINC
only contains a code for delivering that report in the general (unstructured) style. If it contains the
word “Specific” that means it can be delivered as a general structure or as a specific structure –
senders choice. Any clinical report that can be sent as a general style report can also be sent as
image data as defined in Section 2.2. The fourth column references the table in section 4 that
defines the LOINC codes that can be used in the specific, more structured style.
If a report subject identifier code is listed in Table 3.1 as "general," then it may only be
transmitted in the human-decision variant because LOINC codes are not available for section
headings within the report.
Table 3.1 - LOINC Report Subject Identifier Codes
LOINC Code
Report Subject
26443-2 CLINICAL REPORTS.NON LAB (SET)
28650-0
CLINICAL NOTES & CHART SECTIONS (SET)
28562-7
CHART SECTIONS (SET)
11485-0
ANESTHESIA RECORDS
11486-8
CHEMOTHERAPY RECORDS
29751-5
CRITICAL CARE RECORDS
29749-9
DIALYSIS RECORDS
15508-5
LABOR AND DELIVERY RECORDS
11503-0
MEDICAL RECORDS
29750-7
NEONATAL INTENSIVE CARE RECORDS
11543-6
NURSERY RECORDS
29752-3
PERIOPERATIVE RECORDS
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Structure
Type
Section 4
Specific
Structure
General
General
General
General
General
General
General
General
General
NPRM Draft
September 1, 2002
LOINC Code
11534-5
28563-5
28654-2
18741-9
18733-6
28581-7
28580-9
18762-5
28572-6
28583-3
Report Subject
TEMPERATURE CHARTS
CARE PROVIDER NOTES (SET)
ATTENDING PHYSICIAN INITIAL ASSESSMENT
ATTENDING PHYSICIAN PROGRESS NOTE
ATTENDING PHYSICIAN VISIT NOTE
CHIROPRACTOR INITIAL ASSESSMENT
CHIROPRACTOR PROGRESS NOTE
CHIROPRACTOR VISIT NOTE
DENTIST INITIAL ASSESSMENT
DENTIST OPERATIVE NOTE
Structure
Type
General
General
General
General
General
General
General
General
Specific
28577-5
28617-9
28618-7
28622-9
29753-1
28623-7
28651-8
28621-1
28575-9
18764-1
18734-4
11507-1
28578-3
18735-1
11508-9
28579-1
28568-4
11490-0
18736-9
28626-0
DENTIST PROCEDURE NOTE
DENTIST PROGRESS NOTE
DENTIST VISIT NOTE
NURSE HOSPITAL DISCHARGE ASSESSMENT
NURSE INITIAL ASSESSMENT
NURSE INTERVAL ASSESSMENT
NURSE TRANSFER NOTE
NURSE-PRACTITIONER INITIAL ASSESSMENT
NURSE-PRACTITIONER PROGRESS NOTE
NURSE-PRACTITIONER VISIT NOTE
OCCUPATIONAL THERAPY INITIAL ASSESSMENT
OCCUPATIONAL THERAPY PROGRESS NOTE
OCCUPATIONAL THERAPY VISIT NOTE
PHYSICAL THERAPY INITIAL ASSESSMENT
PHYSICAL THERAPY PROGRESS NOTE
PHYSICAL THERAPY VISIT NOTE
PHYSICIAN ED VISIT NOTE
PHYSICIAN HOSPITAL DISCHARGE SUMMARY
PHYSICIAN INITIAL ASSESSMENT
PHYSICIAN HISTORY AND PHYSICAL
General
General
General
General
General
General
General
General
General
General
General
General
General
General
General
General
General
Specific
General
General
28573-4
PHYSICIAN OPERATIVE NOTE
Specific
11505-5
28616-1
28569-2
18763-3
18737-7
28624-5
PHYSICIAN PROCEDURE NOTE
PHYSICIAN TRANSFER NOTE
PHYSICIAN-CONSULTING PROGRESS NOTE
PHYSICIAN-CONSULTING INITIAL ASSESSMENT
PODIATRY INITIAL ASSESSMENT
PODIATRY OPERATIVE NOTE
General
General
General
General
General
Specific
28625-2
11509-7
18765-8
11488-4
15507-7
11492-6
PODIATRY PROCEDURE NOTE
PODIATRY PROGRESS NOTE
PODIATRY VISIT NOTE
PROVIDER-UNSPECIFIED CONSULTING NOTE
PROVIDER-UNSPECIFIED ED VISIT NOTE
PROVIDER-UNSPECIFIED HISTORY AND PHYSICAL
NOTE
PROVIDER-UNSPECIFIED HOSPITAL DISCHARGE
SUMMARY
PROVIDER-UNSPECIFIED INITIAL ASSESSMENT
PROVIDER-UNSPECIFIED OPERATIVE NOTE
General
General
General
General
General
Specific
28574-2
28636-9
11504-8
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Section 4
Specific
Structure
General
General
Specific
(similar to
4.3.2)
4.3.1
(similar to
4.3.3)
(similar to
4.3.2)
(similar to
4.3.2)
4.3.3
(similar to
4.3.1)
4.3.2
NPRM Draft
September 1, 2002
LOINC Code
Report Subject
28570-0
PROVIDER-UNSPECIFIED PROCEDURE NOTE
11506-3
PROVIDER-UNSPECIFIED PROGRESS NOTE
18761-7
PROVIDER-UNSPECIFIED TRANSFER SUMMARY
11542-8
PROVIDER-UNSPECIFIED VISIT NOTE
28635-1
PSYCHIATRY INITIAL ASSESSMENT
28627-8
PSYCHIATRY PROGRESS NOTE
11527-9
PSYCHIATRY REPORT
28628-6
PSYCHIATRY VISIT NOTE
18738-5
PSYCHOLOGY INITIAL ASSESSMENT
11510-5
PSYCHOLOGY PROGRESS NOTE (NARRATIVE
18766-6
PSYCHOLOGY VISIT NOTE
18739-3
SOCIAL SERVICE INITIAL ASSESSMENT
28653-4
SOCIAL SERVICE VISIT NOTE
28656-7
SOCIAL SERVICE PROGRESS NOTE
18740-1
SPEECH THERAPY INITIAL ASSESSMENT
11512-1
SPEECH THERAPY PROGRESS NOTE
28571-8
SPEECH THERAPY VISIT NOTE
27899-4
DIAGNOSTIC STUDIES NON-LAB (SET)
26441-6
CARDIOLOGY STUDIES (SET)
11522-0
CARDIAC ECHO, STUDY
18745-0
CARDIAC CATHETERIZATION, STUDY
11524-6
EKG HEART, STUDY
18750-0
ELECTROPHYSIOLOGY HEART, STUDY
18752-6
EXERCISE STRESS TEST HEART, STUDY
18754-2
HOLTER MONITOR HEART, STUDY
27895-2
GASTROENTEROLOGY ENDOSCOPY STUDIES (SET)
28028-9
ANOSCOPY STUDY
18746-8
COLONOSCOPY LOWER GI TRACT STUDY
28016-4
ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY STUDY
18751-8
ENDOSCOPY UPPER GI TRACT STUDY
28018-0
ENTEROSCOPY STUDY
18753-4
FLEXIBLE SIGMOIDOSCOPY LOWER GI TRACT STUDY
27897-8
NEUROMUSCULAR ELECTROPHYSIOLOGY STUDIES
(SET)
11523-8
ELECTROENCEPHALOGRAM STUDY
18749-2
ELECTROMYOGRAM STUDY
29755-6
NERVE CONDUCTION STUDY
29754-9
NYSTAGMOGRAM STUDY
26442-4
OBSTETRICAL STUDIES (SET)
11525-3
OBSTETRICAL ULTRASOUND PELVIS+FETUS, STUDY
28619-5
OPHTHALMOLOGY/OPTOMETRY STUDIES (SET)
29268-0
CONTACT LENS MEASUREMENTS
29269-8
EYE GLASSES MEASUREMENTS
29271-4
EYE PHYSCIAL EXAMINATION
29272-2
EYE ULTRASOUND STUDY
28632-8
HETEROPHORIA STUDY
28629-4
PERIMETRY (VISUAL FIELD TESTING) STUDY
29270-6
RETINAL TREATMENTS
28630-2
TONOMETRY (GLAUCOMA TESTING) STUDY
28631-0
VISUAL ACUITY (REFRACTION) STUDY
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Structure
Type
Section 4
Specific
Structure
General
General
General
General
General
General
General
General
General
General
General
General
General
General
General
General
General
Specific
General
Specific
General
General
General
4.1.1
4.1.2
General
General
General
General
General
General
General
General
General
General
Specific
4.2.1
†
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
NPRM Draft
September 1, 2002
LOINC Code
27898-6
18743-5
11526-1
11529-5
27896-0
18744-3
28633-6
18759-1
18726-0
11528-7
18782-3
28564-3
28613-8
24946-6
24983-9
24972-2
24762-7
28561-9
24704-9
28565-0
25011-8
24541-5
24709-8
24909-4
28567-6
24891-4
24676-9
24619-9
28582-5
18747-6
11539-4
28566-8
24932-6
24978-9
24963-1
11540-2
11538-6
24866-6
24690-0
24757-7
18755-9
11541-0
18756-7
24935-9
24980-5
24968-0
24629-8
24556-3
24872-4
24707-2
Report Subject
PATHOLOGY STUDY REPORTS (SET)
AUTOPSY REPORT
CYTOLOGY REPORT
SURGICAL PATHOLOGY REPORT
PULMONARY STUDIES (SET)
BRONCHOSCOPY STUDY
POLYSOMNOGRAPHY (SLEEP) STUDY
SPIROMETRY RESPIRATORY SYSTEM, STUDY
RADIOLOGY STUDY REPORTS (SET)
RADIOLOGY UNSPECIFIED MODALITY AND SITE
STUDY
X-RAY UNSPECIFIED SITE STUDY
X-RAY HEAD, STUDY
X-RAY SPINE UNSPECIFIED, STUDY
X-RAY SPINE CERVICAL, STUDY
X-RAY SPINE THORACIC, STUDY
X-RAY SPINE LUMBAR, STUDY
X-RAY HIP, STUDY
X-RAY PELVIS, STUDY
X-RAY FEMUR, STUDY
X-RAY KNEE, STUDY
X-RAY TIBIA AND FIBULA, STUDY
X-RAY ANKLE, STUDY
X-RAY FOOT, STUDY
X-RAY SHOULDER, STUDY
X-RAY HUMERUS, STUDY
X-RAY RADIUS AND ULNA, STUDY
X-RAY ELBOW, STUDY
X-RAY WRIST, STUDY
X-RAY HAND, STUDY
CT UNSPECIFIED SITE, STUDY
CT HEAD, STUDY
CT SPINE, STUDY
CT SPINE CERVICAL, STUDY
CT SPINE THORACIC, STUDY
CT SPINE LUMBAR, STUDY
CT ABDOMEN, STUDY
CT CHEST, STUDY
CT PELVIS, STUDY
CT EXTREMITY, STUDY
CT CORONARY ARTERIES, STUDY
MRI UNSPECIFIED SITE, STUDY
MRI HEAD, STUDY
MRI SPINE, STUDY
MRI SPINE CERVICAL, STUDY
MRI SPINE THORACIC, STUDY
MRI SPINE LUMBAR, STUDY
MRI CHEST, STUDY
MRI ABDOMEN, STUDY
MRI PELVIS AND HIPS, STUDY
MRI FOOT, STUDY
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Structure
Type
Section 4
Specific
Structure
General
General
General
General
General
General
**
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
Specific
4.4.1
4.4.2
4.4.3
4.4.4
NPRM Draft
September 1, 2002
LOINC Code
Report Subject
Structure
Type
Section 4
Specific
Structure
24710-6
28576-7
24720-5
24605-8
24606-6
18757-5
25031-6
24888-0
17787-3
18758-3
25043-1
MRI FOREARM, STUDY
Specific
MRI JOINT, STUDY
Specific
MRI HAND, STUDY
Specific
MAMMOGRAM DIAGNOSTIC VIEWS, STUDY
Specific
MAMMOGRAM SCREENING VIEWS, STUDY
Specific
4.4.5
NUCLEAR MEDICINE UNSPECIFIED STUDY
Specific
NUCLEAR MEDICINE BONE SCAN, STUDY
Specific
4.4.6
NUCLEAR MEDICINE PULMONARY VQ SCAN, STUDY
Specific
NUCLEAR MEDICINE THYROID SCAN, STUDY
Specific
PET SCAN UNSPECIFIED SITE, STUDY
Specific
CT GUIDANCE FOR ASPIRATION OF UNSPECIFIED
Specific
4.4.7
SITE, STUDY
25044-9
CT GUIDANCE FOR BIOPSY OF UNSPECIFIED SITE,
Specific
STUDY
25069-6
FLUOROSCOPIC GUIDANCE FOR BIOPSY OF
Specific
UNSPECIFIED SITE, STUDY
25059-7
ULTRASOUND GUIDANCE FOR BIOPSY OF
Specific
UNSPECIFIED SITE, STUDY
18760-9
ULTRASOUND OF UNSPECIFIED SITE, STUDY
Specific
24875-7
ULTRASOUND PERIPHERAL VESSEL, STUDY
Specific
24731-2
ULTRASOUND HEAD, STUDY
Specific
24842-7
ULTRASOUND NECK, STUDY
Specific
4.4.8
24558-9
ULTRASOUND ABDOMEN, STUDY
Specific
28614-6
ULTRASOUND LIVER, STUDY
Specific
24601-7
ULTRASOUND BREAST, STUDY
Specific
24869-0
ULTRASOUND PELVIS, STUDY
Specific
28634-4
MISCELLANEOUS STUDIES (SET)
18742-7
ARTHROSCOPY REPORT
General
28615-3
AUDIOLOGY STUDY
General
29756-4
PERITONEOSCOPY STUDY
28620-3
UROLOGY STUDY
General
The above represents only a sample of the relevant LOINC codes. See RELMA HIPAA (available at no cost from
http://www.regenstrief.org/loinc/loinc.htm) Table for full set of possible LOINC request codes.
† Examples are not provided in this book. See the RELMA HIPPA table for the specific .
** All Radiology Studies can be transmitted via this same specific report structure as given under Table 4.4.1, 4.4.2, etc.
Table 3.1 Copyright 1995-2003 Regenstrief Institute and the LOINC® Attachment Committee. All rights reserved.
3.2
Scope Modification Codes
The LOINC publication LOINC Modifier Codes as used in the ASC X12N 277 Implementation
Guide (004050X104) Health Care Claim Request for Additional Information provides code
values for further defining the specificity of a request for additional information. Both time
window and item selection modifier codes are defined.
3.3
Report Structures
Table 3.3 describes the manner in which general or specific report structures are used to create
human-decision or computer-decision variants.
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Table 3.3 - Specific/General vs Human/Computer-Decision Variant
Description in
Table 3.1
General
Specific
Use for Human-Decision Variant?
Yes
Yes, provider can create sections ad hoc.
Provider may use some or all of the
sections and associated LOINC codes
from the table in section 4.
Use for Computer-Decision Variant?
No
Yes, provider must follow the table in
section 4 and structure data according to
data type specifications.
3.3.1 General Report Structure
The general report structure applies to all clinical reports including all of those in Table 3.1,
whether they are labeled "specific" or "general."
When using the general report structure, the sender shall send the Report Subject Identifier Code
<document_type_cd> element in the CDA header. The sender is not required to include
<caption_cd> elements in the body of the CDA document. However, where pertinent LOINC
codes exist for sections or content elements within the CDA the provider may send them in the
<caption_cd> elements wherever they apply.
3.3.2 Specific Report Structure
Where an entry in table 3.1 indicates that a specific report structure is available it identifies a
table in section 4 that contains that structure. The provider may use the information in section 4 to
create a computer-decision variant attachment. The provider may also create a human-decision
variant for reports that are identified as specific.
Human Decision Variant. To create a human-decision variant attachment for a report type that
is listed in table 3.1 as "specific", the sender sends the Report Subject Identifier Code
<document_type_cd> element in the CDA header. The sender is not required to include
<caption_cd> elements in the body of the CDA document. However, where pertinent LOINC
codes exist for sections or content elements within the CDA the provider may send them in the
<caption_cd> elements wherever they apply. The sender may choose to use the LOINC codes and
captions from the corresponding table in section 4, but this is not required.
Computer-Decision Variant. To create a report in the computer-decision variant the sender must
follow the specifications from a table in section 4 with respect to data type, cardinality and the
use of coded responses.
If the data type code in the table is NM (numeric) the transmitted value should be reported with
appropriate units specified as specified for the numeric data type in HL7 Additional Information
Specification Implementation Guide.
If the data type code in the table is CE, the content of the corresponding element of the CDA
document must include the textual interpretation of the code.
Note that the ability to use a section 4 table to create a computer-decision variant does not
guarantee that such an attachment is suitable for autoadjudication. A payer would need to make a
business decision to autoadjudicate by examining the coded and numeric elements to see if they
provide the necessary data for a decision. Some of the elements in the tables in section 4 are of
type TX. A compliant, "computer-decision variant" attachment may not be suitable for
autoadjudication if a decision would rely on data in an element of type TX.
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3.3.3 Coding Example – General report format
Scenario: A message was created on August 14, 1998 at 5:39:24 AM.
The patient name is Patient H. Sample. The medical record ID of the patient for the sending
institution is 6910828. The billing account number within the sending institution that is
associated with the claim is 773789090.
The provider is Ken Cure, MD, who is identified as ID number A522 by the hospital. Dr. Cure
signed the note on 30 October 1998 at 12:53 PM.
The document contains a discharge note identified by LOINC code 11490-0.
Document
Header
document type
<levelone xmlns="urn:hl7-org:v3/cda" xmlns:v3dt="urn:hl7-org:v3/v3dt"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7org:v3/cda
C:\DOCUME~1\wrishel\MYDOCU~1\HL7\CDA\R1Schemas\FromVassil\levelone_1.0.wes.xsd
">
<clinical_document_header>
<id EX="a123" RT="2.16.840.1.113883.3.933"/>
<document_type_cd V="11490-0"
DN="PHYSICIAN HOSPITAL DISCHARGE SUMMARY"/>
<origination_dttm V="1998-10-28"/>
origination date
Authenticator
element used to
convey the
signature
Provider element
identifies the
provider. In this
case it is the same
as the
authenticator.
Patient
identification
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<authenticator>
<authenticator.type_cd V="VRF"/>
<participation_tmr V="1998-10-30T12:53"/>
<signature_cd V="S"/>
<person>
<id EX="A522" RT="2.16.840.1.113883.3.933"/>
<person_name>
<nm>
<v3dt:GIV V="Ken"/>
<v3dt:FAM V="Cure"/>
<v3dt:SFX V="MD" QUAL="PT"/>
</nm>
<person_name.type_cd V="L" S="2.16.840.1.113883.5.200"/>
</person_name>
</person>
</authenticator>
<provider>
<provider.type_cd V="PRF"/>
<person>
<id EX="298379" RT="2.16.840.1.113883.3.933"/>
<person_name>
<nm>
<v3dt:GIV V="Ken"/>
<v3dt:FAM V="Cure"/>
<v3dt:SFX V="MD" QUAL="PT"/>
</nm>
<person_name.type_cd V="L" S="2.16.840.1.113883.5.200"/>
</person_name>
</person>
</provider>
<patient>
<patient.type_cd V="PATSBJ"/>
<person>
<id EX="6910828" RT="2.16.840.1.113883.3.933"/>
<person_name>
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<nm>
<v3dt:GIV V="Patient"/>
<v3dt:FAM V="Sample"/>
<v3dt:MID V="H"/>
</nm>
<person_name.type_cd V="L" S="2.16.840.1.113883.5.200"/>
</person_name>
</person>
<administrative_gender_cd V="F"/>
</patient>
end of header
start body
first section is
hospital discharge
diagnoses,
presented using
the CDA <list>
element
Caption codes
permitted, but
not required in
human decision
variant.
Remaining
sections
</clinical_document_header>
<body>
<section>
<caption>HOSPITAL DISCHARGE DX<caption_cd V="11535-2"/>
</caption>
<list list_type="ordered">
<item>
<content>Metastatic breast cancer.</content>
</item>
<item>
<content>Malignant pleural effusion.</content>
</item>
</list>
</section>
<section>
<caption>HOSPITAL DISCHARGE PROCEDURES<caption_cd V="10185-7"/>
</caption>
<paragraph>
<content>1. Thoracoscopy with chest tube placement and
pleurodesis.</content>
</paragraph>
</section>
<section>
<caption>HISTORY OF PRESENT ILLNESS <caption_cd V="10164-2"/>
</caption>
<paragraph>
<content> The patient is a very pleasant, 70-year-old
female with a history of breast cancer that was
originally diagnosed in the early 70's. At that
time she had a radical mastectomy with postoperative
radiotherapy. In the mid 70's she developed a chest
wall recurrence and was treated with further radiation
therapy. She then went without evidence of disease
for many years until the late 80's when she developed
bone metastases with involvement of her sacroiliac
joint, right trochanter, and left sacral area. She was
started on Tamoxifen at that point in time and has done
well until recently when she developed shortness of
breath and was found to have a larger pleural effusion.
This has been tapped on two occasions and has rapidly
reaccumulated so she was admitted at this time for
thoracoscopy with pleurodesis. Of note, her CA15-3 was
44 in the mid 90's and recently was found to be 600.</content>
</paragraph>
</section>
<section>
<caption>HOSPITAL DISCHARGE PHYSICAL FINDINGS
<caption_cd V="10184-0"/>
</caption>
<paragraph>
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<content>Physical examination at the time of admission
revealed a thin, pleasant female in mild respiratory
distress. She had no adenopathy. She had decreased
breath sounds three fourths of the way up on the
right side. The left lung was mostly clear although
there were a few scattered rales. Cardiac examination
revealed a regular rate and rhythm without murmurs.
She had no hepatosplenomegaly and no peripheral
clubbing, cyanosis, or edema.</content>
</paragraph>
</section>
<section>
<caption>HOSPITAL DISCHARGE STUDIES SUMMARY
<caption_cd V="11493-4"/>
</caption>
<paragraph>
<content> A chest x-ray showed a large pleural effusion on
the right.</content>
</paragraph>
</section>
<section>
<caption>HOSPITAL COURSE
<caption_cd V="8648-8"/>
</caption>
<paragraph>
<content>The patient was admitted. A CT scan was
performed which showed a possibility that the lung was
trapped by tumor and that there were some adhesions.
The patient then underwent thoracoscopy which confirmed
the presence of a pleural peel of tumor and multiple
adhesions which were taken down. Two chest tubes were
subsequently placed. These were left in place for
approximately four days after which a TALC slurry
was infused and the chest tubes were removed the
following day. Because of the significant pleural
peel and the trapped lungs, it is clearly possible
that the pleurodesis will not be successful and
this was explained to the patient and the family
prior to the procedure.</content>
</paragraph>
<paragraph>
<content>
Of note, we started her on Megace during this
hospitalization because she was having significant
nausea and vomiting with the Arimidex that she had
been taking.</content>
</paragraph>
</section>
<section>
<caption>HOSPITAL DISCHARGE FOLLOWUP <caption_cd V="11544-4"/>
</caption>
<paragraph>
<content> The patient is being transferred to an
extended-care facility near her home, where she
will remain until she has enough strength to go
home. It is possible that the fluid may
reaccumulate and require repeat tapping
despite the pleurodesis that was performed.
Hopefully, however, with the combination of
pleurodesis and the Megace that she was
started on, she will have improvement of
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close body
element
close entire CDA
document
her cancer and a decrease in her pulmonary
symptomatology. Overall, however, her
prognosis is poor because of her debilitated
state and the status of her lungs.</content>
</paragraph>
<paragraph>
<content>
She is being discharged on Tylenol with Codeine as
needed for pain, Megace, and a Multivitamin.
She will have a follow-up appointment with Dr.
Follow in three weeks with a chest x-ray. They
have been instructed to call us in the interim
should there be any problems.</content>
</paragraph>
</section>
</body>
</levelone>
Figure 1 (continued over two pages) contains a screen shot of this CDA document as rendered in
a commonly used Web browser using the current HL7-suppled XSL style sheet.
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Figure 1. Hospital discharge summary, human-decision variant.
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4 Value Tables for Specific Report Structures
If the report subject has a specific report structure, signified by the word “specific” in the
Structure column of Table in 3.1, or by a substructure on the HIPAA RELMA display for this
report subject, the sender may elect to use <caption_cd> elements based with the LOINC codes
contained in tables in this section. These <caption_cd> elements are permitted in the humandecision variant and required in the computer-decision variant.
Senders can choose to include the codes within the specific structure that make sense for their
reports. Most structured reports would include only a small percent of the total number of
observation codes listed in the specific structure for a given report.
Requestors can use any LOINC code that is contained in the hierarchy of clinical reports.non lab
(LOINC 26443-2) as the report subject identifier in a 277 request message. These codes can be
found in the LOINC database and viewed via the RELMA program. You can see all LOINC
codes contained within clinical reports.non lab by choosing the HIPAA attachment task in
RELMA.
As non-laboratory diagnostic technology improves over time and new provider note titles are
developed, the LOINC Committee will create new LOINC codes (and sets of codes) to represent
them. These will then become valid subject codes for requests in the X12 277 under the clinical
reports attachment.
Note this booklet does not cover laboratory results. The way to send laboratory results as an
attachment is described in the Laboratory attachments booklet.
Should we be removing signing practitioner from all of these tables?
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4.1
Cardiac Diagnostic Studies
4.1.1 Cardiac Echo Study
Cardiac echoes can be sent in a general or specific report structure. The following table lists some
of codes that can be used to produce a specific structure. This table provides a rich sample of the
cardiac echo observation codes available within LOINC, but it is only a sample. To see the full
set of LOINC codes available for reporting the details of a cardiac echo look in the hierarchy
beneath cardiac echo studies (115220-0) in the HIPAA task of RELMA.
Table 4.1.1 - Cardiac Echo Study
LOINC code
11522-0
18011-7
18012-5
18013-3
18014-1
18015-8
18010-9
18016-6
17981-2
18835-9
18061-2
18062-0
18063-8
18066-1
18068-7
18089-3
19006-6
18839-1
18106-5
18838-3
18836-7
18146-1
Short Name
CARDIAC ECHO STUDY
AORTA ARCH, DIAMETER (ECHO)
AORTA ASCENDING, DIAMETER (ECHO)
AORTA DESCENDING, DIAMETER (ECHO)
AORTA ISTHMUS, DIAMETER (ECHO)
AORTA ROOT, DIAMETER (ECHO)
AORTA, DIAMETER (ECHO)
AORTIC VALVE ORIFICE, DIAMETER (ECHO)
AORTIC VALVE, ACCELERATION (US
DOPPLER)
AORTIC VALVE, AREA METHOD
(NARRATIVE)
AORTIC VALVE, GRADIENT SYSTOLE MAX
PRESSURE (US DOPPLER DERIVED FULL
BERNOULLI)
AORTIC VALVE, GRADIENT SYSTOLE MAX
PRESSURE (US DOPPLER DERIVED
SIMPLIFIED BERNOULLI)
AORTIC VALVE, GRADIENT SYSTOLE MEAN
PRESSURE (US DOPPLER DERIVED
SIMPLIFIED BERNOULLI)
AORTIC VALVE, GRADIENT SYSTOLE MEAN
PRESSURE (US DOPPLER DERIVED FULL
BERNOULLI)
AORTIC VALVE, INTERVAL FROM Q-WAVE
TO AORTIC VALVE OPENS (EKG US)
AORTIC VALVE, ORIFICE AREA (ECHO)
CARDIAC ECHO IMAGING DEVICE, IMAGE
QUALITY (NARRATIVE) (ECHO)
CARDIAC ECHO IMAGING DEVICE,
ULTRASOUND CLASS (NARRATIVE)
CARDIAC ECHO STUDY, PROCEDURE
CARDIAC ECHO STUDY, TRANSDUCER SITE
(NARRATIVE)
CARDIAC STRESS STUDY, PROCEDURE
(NARRATIVE)
CARDIOVASCULAR CENTRAL, STUDY
OBSERVATION OVERALL (NARRATIVE)
(ECHO)
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Data
Type
Card
NM
NM
NM
NM
NM
NM
NM
NM
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
TX
0,1
NM
0,1
NM
0,1
NM
0,1
NM
0,1
NM
0,1
NM
TX
0,1
0,1
TX
0,1
TX
TX
0,1
0,1
TX
0,1
TX
0,1
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Response Code
or
Numeric Units
NPRM Draft
September 1, 2002
LOINC code
18141-2
18143-8
18144-6
18024-0
18070-3
18069-5
18018-2
18064-6
18043-0
18087-7
18837-5
18118-0
18840-9
18078-6
18079-4
18054-7
17985-3
18025-7
17979-6
17980-4
18017-4
18057-0
18058-8
Short Name
CARDIOVASCULAR CENTRAL, ECHO
OBSERVATION (NARRATIVE)
ECHO HEART CHAMBERS, STUDY
OBSERVATION (NARRATIVE)
HEART VALVES, ECHO OBSERVATION
(NARRATIVE)
HEART ATRIUM LEFT, DIAMETER
ANTERIOR-POSTERIOR SYSTOLE (US MMODE)
HEART ATRIUM RIGHT, INTRACHAMBER
MEAN PRESSURE (ECHO)
HEART ATRIUM RIGHT, INTRACHAMBER
MEAN PRESSURE (ESTIMATED FROM
JUGULAR VENOUS DISTENTION)
HEART VENTRICLE LEFT OUTFLOW-TRACT,
DIAMETER (ECHO)
HEART VENTRICLE LEFT OUTFLOW-TRACT,
GRADIENT SYSTOLE MAX PRESSURE (US
DOPPLER)
HEART VENTRICLE LEFT, EJECTION
FRACTION VFR (ECHO)
HEART VENTRICLE LEFT, MYOCARDIUM
MASS (ECHO)
HEART VENTRICLE LEFT, SEGMENTAL
WALL APPEARANCE FINDING (NARRATIVE)
(ECHO)
HEART VENTRICLE LEFT, SEGMENTAL
WALL MOTION FINDING (NARRATIVE)
(ECHO)
HEART VENTRICLE LEFT, WALL MOTION
INDEX (NARRATIVE) (ECHO)
HEART VENTRICLE RIGHT, MAJOR AXIS
DIASTOLE MAX LENGTH (US 2D)
HEART VENTRICLE RIGHT, MAJOR AXIS
SYSTOLE MIN LENGTH (US 2D)
HEART VENTRICLE SEPTUM, FRACTIONAL
THICKNESS LENFR (US 2D)
HEART, AP DIMENSION LEFT ATRIUM/AP
DIMENSION AORTA ROOT RATIO (ECHO)
HEART, DIAMETER ANTERIOR-POSTERIOR
SYSTOLE/DIAMETER AORTA ROOT RATIO
(ECHO)
MITRAL VALVE ANTERIOR LEAFLET, A-C
DURATION (US M-MODE)
MITRAL VALVE ANTERIOR LEAFLET, A-C
SLOPE (US M-MODE)
MITRAL VALVE ORIFICE, DIAMETER (ECHO)
MITRAL VALVE, GRADIENT MAX PRESSURE
(US DOPPLER)
PULMONIC VALVE, GRADIENT MAX
PRESSURE (US DOPPLER)
Clinical Reports Attachments
V24AIM0004R010
Data
Type
Card
TX
0,1
TX
0,1
TX
0,1
NM
0,1
NM
0,1
NM
0,1
NM
0,1
NM
0,1
NM
0,1
NM
0,1
TX
0,1
TX
0,1
TX
0,1
NM
0,1
NM
0,1
NM
0,1
NM
0,1
NM
0,1
NM
0,1
NM
0,1
NM
NM
0,1
0,1
NM
0,1
19
Health Level Seven, Inc. © 1998-2002. All rights reserved
Response Code
or
Numeric Units
NPRM Draft
September 1, 2002
LOINC code
18059-6
18097-6
18019-0
18020-8
18095-0
18021-6
18022-4
17982-0
18060-4
18096-8
18023-2
18065-3
17983-8
Short Name
MITRAL VALVE, GRADIENT MEAN
PRESSURE (US DOPPLER)
MITRAL VALVE, ORIFICE MIN AREA (US
DOPPLER PRESSURE HALFTIME)
PULMONARY ARTERY LEFT, DIAMETER
(ECHO)
PULMONARY ARTERY MAIN, DIAMETER
(ECHO)
PULMONARY ARTERY MAIN, ORIFICE AREA
(ECHO)
PULMONARY ARTERY RIGHT, DIAMETER
(ECHO)
PULMONIC VALVE ORIFICE, DIAMETER
(ECHO)
PULMONIC VALVE, ACCELERATION (US
DOPPLER)
PULMONIC VALVE, GRADIENT MEAN
PRESSURE (US DOPPLER)
PULMONIC VALVE, ORIFICE AREA (US
CONTINUITY)
TRICUSPID VALVE ORIFICE, DIAMETER
(ECHO)
TRICUSPID VALVE REGURGITANT JET,
GRADIENT SYSTOLE MAX PRESSURE (US
DOPPLER)
TRICUSPID VALVE, ACCELERATION (US
DOPPLER)
Data
Type
Card
NM
0,1
NM
0,1
NM
0,1
NM
0,1
NM
0,1
NM
0,1
NM
0,1
NM
0,1
NM
0,1
NM
0,1
NM
0,1
NM
0,1
NM
0,1
Response Code
or
Numeric Units
See LOINC RELMA HIPAA Table for full set of possible LOINC request codes.
Table 4.1.1 Copyright 1995-2003 Regenstrief Institute and the LOINC® Attachment Committee. All rights reserved.
4.1.2
EKG STUDY
EKGs can be sent in a general or specific report structure. The following table lists some of the
more important codes available for a specific structure. This table provides a sample of the EKG
codes available within LOINC but it is only a sample. To see the full set of LOINC codes
available for reporting the details of a EKG in a structured form, look in the hierarchy beneath
EKG Studies (#11524-6) in the HIPAA task of RELMA.
Table 4.1.2 - EKG STUDY
LOINC code
11524-6
9866-5
9867-3
18843-3
8598-5
9868-1
Short Name
EKG STUDY
HEART, AXIS (NARRATIVE) (EKG)
HEART, CARDIAC PACEMAKER PROSTHETIC
(NARRATIVE) (EKG)
HEART, COMPARISON STUDY (NARRATIVE)
(EKG)
HEART, COMPARISON STUDY DATE AND
TIME (EKG)
HEART, CONDUCTION (NARRATIVE) (EKG)
Clinical Reports Attachments
V24AIM0004R010
Data
Type
Card
TX
TX
0,1
0,1
0,1
TX
0,1
TS
0,1
TX
0,1
20
Health Level Seven, Inc. © 1998-2002. All rights reserved
Response Code
or
Numeric Units
NPRM Draft
September 1, 2002
LOINC code
18844-1
9869-9
9872-3
8626-4
18506-6
8627-2
18504-1
8625-6
8631-4
8632-2
18507-4
9873-1
8633-0
8634-8
9874-9
18505-8
18510-8
9875-6
18810-2
8638-9
8621-5
18845-8
18516-5
18512-4
18511-6
18517-3
18514-0
18513-2
18518-1
18515-7
9876-4
Short Name
HEART, EKG IMPRESSION (NARRATIVE)
(EKG)
HEART, HYPERTROPHY (NARRATIVE) (EKG)
HEART, MYOCARDIAL ISCHEMIA
(NARRATIVE) (EKG)
HEART, P WAVE AXIS ANGLE (EKG)
HEART, P WAVE AXIS HORIZONTAL PLANE
ANGLE (EKG)
HEART, P WAVE DURATION (EKG)
HEART, PP INTERVAL (EKG)
HEART, PR INTERVAL (EKG)
HEART, Q WAVE DURATION (EKG)
HEART, QRS AXIS ANGLE (EKG)
HEART, QRS AXIS HORIZONTAL PLANE
ANGLE (EKG)
HEART, QRS COMPLEX (NARRATIVE) (EKG)
HEART, QRS DURATION (EKG)
HEART, QT INTERVAL (EKG)
HEART, RHYTHM SEGMENT (NARRATIVE)
(EKG)
HEART, RR INTERVAL (EKG)
HEART, ST SEGMENT AXIS HORIZONTAL
PLANE ANGLE (EKG)
HEART, ST-T SEGMENT (NARRATIVE) (EKG)
HEART, STUDY OBSERVATION OVERALL
FINDING (NARRATIVE) (EKG)
HEART, T WAVE AXIS ANGLE (EKG)
HEART, VENTRICULAR ECTOPICS RATE
(EKG)
REFERENCE BEAT TYPE (NARRATIVE) (EKG)
REFERENCE BEAT, P WAVE AXIS FRONTAL
PLANE ANGLE (EKG)
REFERENCE BEAT, P WAVE OFFSET TIME
(EKG)
REFERENCE BEAT, P WAVE ONSET TIME
(EKG)
REFERENCE BEAT, QRS AXIS FRONTAL
PLANE ANGLE (EKG)
REFERENCE BEAT, QRS OFFSET TIME (EKG)
REFERENCE BEAT, QRS ONSET TIME (EKG)
REFERENCE BEAT, T WAVE AXIS FRONTAL
PLANE ANGLE (EKG)
REFERENCE BEAT, T WAVE OFFSET TIME
(EKG)
VENTRICULAR MORPHOLOGY (NARRATIVE)
(EKG)
Data
Type
Card
TX
0,1
TX
TX
0,1
0,1
NM
NM
0,1
0,1
NM
NM
NM
NM
NM
NM
0,1
0,1
0,1
0,1
0,1
0,1
TX
NM
NM
TX
0,1
0,1
0,1
0,1
NM
NM
0,1
0,1
TX
TX
0,1
0,1
NM
NM
0,1
0,1
TX
NM
0,1
0,1
NM
0,1
NM
0,1
NM
0,1
NM
NM
NM
0,1
0,1
0,1
NM
0,1
TX
0,1
Response Code
or
Numeric Units
See LOINC RELMA HIPAA Table for full set of possible LOINC request codes.
Table 4.1.2 Copyright 1995-2003 Regenstrief Institute and the LOINC® Attachment Committee. All rights reserved.
Clinical Reports Attachments
V24AIM0004R010
21
Health Level Seven, Inc. © 1998-2002. All rights reserved
NPRM Draft
September 1, 2002
4.2
Obstetrical Studies
4.2.1 OB Ultrasound Study
OB Ultrasounds can be sent in a general or specific report structure. The rules for sending general
and specific structures are the same as for the preceeding tables. The following table lists some of
the codes that can be used to produce a specific structure for obstetrical ultrasounds. This table is
provided as a sample of the OB Ultrasounds codes available within LOINC, but it is just a
sample. To see the full set of LOINC codes available for reporting the OB Ultrasound content in a
structured format look in the hierarchy beneath OB Ultrasound Study (#11525-3) in the HIPAA
task of RELMA.
Table 4.2.1 - OB Ultrasound Study
LOINC code
11525-3
11727-5
11636-8
11637-6
11638-4
11639-2
11640-0
11867-9
11778-8
11779-6
11780-4
11781-2
12145-9
18846-6
11627-7
12167-3
12171-5
12170-7
11616-0
11618-6
12146-7
18851-6
Short Name
OBSTETRICAL ULTRASOUND STUDY
FETUS, BODY WEIGHT (ULTRASOUND
ESTIMATED)
BIRTHS LIVE (REPORTED)
BIRTHS PRETERM (REPORTED)
BIRTHS STILL LIVING (REPORTED)
BIRTHS TERM (REPORTED)
BIRTHS TOTAL (REPORTED)
CERVIX, EFFACEMENT PERCENTILE
(PALPATION)
DELIVERY DATE (CLINICAL ESTIMATE)
DELIVERY DATE (ESTIMATED FROM LAST
MENSTRUAL PERIOD)
DELIVERY DATE (ESTIMATED FROM
OVULATION DATE)
DELIVERY DATE (ULTRASOUND COMPOSITE
ESTIMATED)
ENDOMETRIUM, THICKNESS (ULTRASOUND
MEASURED)
EXAMINATION LEVEL ULTRASOUND
(NARRATIVE)
FETUS AMNIOTIC FLUID, INDEX SUM
LENGTH (ULTRASOUND DERIVED)
FETUS AMNIOTIC FLUID, VOLUME
AMNIOTIC FLUID (ULTRASOUND)
FETUS HEAD LATERAL CEREBRAL
VENTRICLES, WIDTH TRANSVERSE
(ULTRASOUND MEASURED)
FETUS HEAD, WIDTH HEMISPHERE
(ULTRASOUND MEASURED)
FETUS HEART, ACTIVITY FINDING
(NARRATIVE) (ULTRASOUND)
FETUS LIMBS, ACTIVITY FINDING
(NARRATIVE) (ULTRASOUND)
FETUS NUCHAL FOLD, THICKNESS
(ULTRASOUND MEASURED)
FETUS PLACENTA, GRADE (NARRATIVE)
(ULTRASOUND)
Clinical Reports Attachments
V24AIM0004R010
Data
Type
Card
NM
0,1
NM
NM
NM
NM
NM
NM
0,1
0,1
0,1
0,1
0,1
0,1
DT
DT
0,1
0,1
DT
0,1
DT
0,1
NM
0,1
NM
0,1
NM
0,1
ST
0,1
NM
0,1
NM
0,1
TX
0,1
TX
0,1
NM
0,1
ST
0,1
22
Health Level Seven, Inc. © 1998-2002. All rights reserved
Response Code
or
Numeric Units
NPRM Draft
September 1, 2002
LOINC code
12147-5
11620-2
11952-9
11766-3
11768-9
11883-6
11884-4
11885-1
11886-9
11887-7
11947-9
11948-7
11950-3
11949-5
11951-1
11957-8
12130-1
11878-6
11955-2
11767-1
11769-7
11879-4
11880-2
11976-8
19021-5
Short Name
FETUS PLACENTA, THICKNESS
(ULTRASOUND MEASURED)
FETUS RESPIRATORY SYSTEM, ACTIVITY
FINDING (NARRATIVE) (ULTRASOUND)
FETUS UMBILICAL CORD PLACENTA,
INSERTION SITE FINDING (NARRATIVE)
(ULTRASOUND)
FETUS, BODY WEIGHT PERCENTILE (COMP
OF EST FETAL WGT W STD POP DIST AT
SAME ESTGA)
FETUS, BODY WEIGHT PERCENTILE RANGE
PERCENTILE (CATEGORIZATION BY
COMPARISON WITH STANDARDS)
FETUS, GENDER FINDING (NARRATIVE)
(ULTRASOUND)
FETUS, GESTATIONAL AGE (CLINICAL
ESTIMATE)
FETUS, GESTATIONAL AGE (ESTIMATED
FROM LAST MENSTRUAL PERIOD)
FETUS, GESTATIONAL AGE (ESTIMATED
FROM OVULATION DATE)
FETUS, GESTATIONAL AGE (ESTIMATED
FROM SELECTED DELIVERY DATE)
FETUS, HEAD
CIRCUMFERENCE/ABDOMINAL
CIRCUMFERENCE RATIO (ULTRASOUND
DERIVED)
FETUS, HEART RATE (ULTRASOUND
MEASURED)
FETUS, IDENTIFICATION CRITERIA FINDING
(NARRATIVE) (ULTRASOUND)
FETUS, IDENTIFICATION CRITERIA FINDING
(ULTRASOUND)
FETUS, IDENTIFIER
FETUS, LENGTH CROWN RUMP
(ULTRASOUND MEASURED)
FETUS, STUDY OBSERVATION GENERAL
(NARRATIVE) (ULTRASOUND)
FETUSES (ULTRASOUND)
LAST MENSTRUAL PERIOD DATE AND TIME
(REPORTED)
MOTHER BODY WEIGHT PERCENTILE (COMP
OF EST FETAL WGT W STD POP DIST AT
SAME ESTGA)
MOTHER BODY WEIGHT PERCENTILE
RANGE PERCENTILE (CATEGORIZATION BY
COMPARISON WITH STANDARDS)
OVARY LEFT, FOLLICLES (ULTRASOUND)
OVARY RIGHT, FOLLICLES (ULTRASOUND)
OVULATION DATE (REPORTED)
PALPATION CERVIX, STUDY OBSERVATION
(NARRATIVE)
Clinical Reports Attachments
V24AIM0004R010
Data
Type
Card
NM
0,1
TX
0,1
TX
0,1
NM
0,1
NM
0,1
TX
0,1
NM
0,1
NM
0,1
NM
0,1
NM
0,1
NM
0,1
NM
0,1
TX
0,1
ST
0,1
ST
NM
0,1
0,1
TX
0,1
NM
TS
0,1
0,1
NM
0,1
NM
0,1
NM
NM
TS
TX
0,1
0,1
0,1
0,1
23
Health Level Seven, Inc. © 1998-2002. All rights reserved
Response Code
or
Numeric Units
NPRM Draft
September 1, 2002
LOINC code
11977-6
18847-4
18848-2
18849-0
18850-8
12132-7
19008-2
12157-4
12029-5
12030-3
12031-1
12032-9
12033-7
12034-5
12035-2
12037-8
12039-4
12041-0
12043-6
12048-5
12050-1
12052-7
12054-3
12056-8
12058-4
12059-2
Short Name
PARITY (REPORTED)
PELVIS, FETAL POSITION (NARRATIVE)
(PALPATION)
PELVIS, FETAL POSITION (NARRATIVE)
(ULTRASOUND)
PELVIS, FETAL PRESENTATION
(NARRATIVE) (PALPATION)
PELVIS, FETAL PRESENTATION
(NARRATIVE) (ULTRASOUND)
STUDY OBSERVATION GENERAL
(NARRATIVE) (ULTRASOUND)
TRANSDUCER SITE (NARRATIVE)
ULTRASONOGRAPHER GRAVIDITY NUMBER
ULTRASOUND FETUS ABDOMEN, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND FETUS ABDOMINAL WALL,
STUDY OBSERVATION
ULTRASOUND FETUS ABDOMINAL WALL,
STUDY OBSERVATION (NARRATIVE)
ULTRASOUND FETUS AORTA ASCENDING,
STUDY OBSERVATION
ULTRASOUND FETUS AORTA ASCENDING,
STUDY OBSERVATION (NARRATIVE)
ULTRASOUND FETUS AORTA DESCENDING,
STUDY OBSERVATION
ULTRASOUND FETUS AORTA DESCENDING,
STUDY OBSERVATION (NARRATIVE)
ULTRASOUND FETUS AORTA, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND FETUS AORTIC ARCH, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND FETUS CEREBELLUM, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND FETUS CEREBRUM, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND FETUS COLON, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND FETUS CRANIUM, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND FETUS DIAPHRAGM, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND FETUS DUCTAL ARCH,
STUDY OBSERVATION (NARRATIVE)
ULTRASOUND FETUS FACE, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND FETUS HEAD CHOROID
PLEXUS, STUDY OBSERVATION
(NARRATIVE)
ULTRASOUND FETUS HEAD FOURTH
VENTRICLE, STUDY OBSERVATION
Clinical Reports Attachments
V24AIM0004R010
Data
Type
Card
NM
TX
0,1
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
NM
TX
0,1
0,1
0,1
ST
0,1
TX
0,1
ST
0,1
TX
0,1
ST
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
NM
0,1
24
Health Level Seven, Inc. © 1998-2002. All rights reserved
Response Code
or
Numeric Units
NPRM Draft
September 1, 2002
LOINC code
12060-0
12062-6
12064-2
12070-9
12072-5
12073-3
12074-1
12076-6
12078-2
12081-6
12082-4
12083-2
12084-0
12087-3
12088-1
12089-9
12090-7
12091-5
12093-1
12095-6
12097-2
12099-8
Short Name
ULTRASOUND FETUS HEAD FOURTH
VENTRICLE, STUDY OBSERVATION
(NARRATIVE)
ULTRASOUND FETUS HEAD INTRACRANIAL
ANATOMY, STUDY OBSERVATION
(NARRATIVE)
ULTRASOUND FETUS HEAD LATERAL
CEREBRAL VENTRICLES, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND FETUS HEAD, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND FETUS HEART AORTIC
VALVE, STUDY OBSERVATION (NARRATIVE)
ULTRASOUND FETUS HEART ATRIA, STUDY
OBSERVATION
ULTRASOUND FETUS HEART ATRIA, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND FETUS HEART CHAMBERS,
STUDY OBSERVATION (NARRATIVE)
ULTRASOUND FETUS HEART GREAT
VESSELS, STUDY OBSERVATION
(NARRATIVE)
ULTRASOUND FETUS HEART MITRAL
VALVE, STUDY OBSERVATION
ULTRASOUND FETUS HEART MITRAL
VALVE, STUDY OBSERVATION (NARRATIVE)
ULTRASOUND FETUS HEART PULMONARY
VALVE, STUDY OBSERVATION
ULTRASOUND FETUS HEART TRICUSPID
VALVE, STUDY OBSERVATION
ULTRASOUND FETUS HEART VALVES,
STUDY OBSERVATION (NARRATIVE)
ULTRASOUND FETUS HEART VENTRICULAR
OUTFLOW TRACT LEFT, STUDY
OBSERVATION
ULTRASOUND FETUS HEART VENTRICULAR
OUTFLOW TRACT LEFT, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND FETUS HEART VENTRICULAR
OUTFLOW TRACT RIGHT, STUDY
OBSERVATION
ULTRASOUND FETUS HEART VENTRICULAR
OUTFLOW TRACT RIGHT, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND FETUS INTESTINE, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND FETUS KIDNEY LEFT, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND FETUS KIDNEY RIGHT,
STUDY OBSERVATION (NARRATIVE)
ULTRASOUND FETUS KIDNEY, STUDY
OBSERVATION (NARRATIVE)
Clinical Reports Attachments
V24AIM0004R010
Data
Type
Card
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
ST
0,1
TX
0,1
TX
0,1
TX
0,1
NM
0,1
TX
0,1
NM
0,1
NM
0,1
TX
0,1
NM
0,1
TX
0,1
NM
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
25
Health Level Seven, Inc. © 1998-2002. All rights reserved
Response Code
or
Numeric Units
NPRM Draft
September 1, 2002
LOINC code
12101-2
12103-8
12105-3
12107-9
12109-5
12111-1
12113-7
12115-2
12117-8
12119-4
12121-0
12123-6
12125-1
12128-5
12066-7
12067-5
12068-3
Short Name
ULTRASOUND FETUS LIMBS, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND FETUS NUCHAL FOLD, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND FETUS PULMONARY ARTERY,
STUDY OBSERVATION (NARRATIVE)
ULTRASOUND FETUS PULMONARY VEIN,
STUDY OBSERVATION (NARRATIVE)
ULTRASOUND FETUS SMALL BOWEL,
STUDY OBSERVATION (NARRATIVE)
ULTRASOUND FETUS SPINE, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND FETUS STOMACH, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND FETUS THORAX, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND FETUS UMBILICAL CORD,
STUDY OBSERVATION (NARRATIVE)
ULTRASOUND FETUS URINARY BLADDER,
STUDY OBSERVATION (NARRATIVE)
ULTRASOUND FETUS VENA CAVA
INFERIOR, STUDY OBSERVATION
(NARRATIVE)
ULTRASOUND FETUS VENA CAVA
SUPERIOR, STUDY OBSERVATION
(NARRATIVE)
ULTRASOUND FETUS VENA CAVA, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND FETUS YOLK SAC, STUDY
OBSERVATION (NARRATIVE)
ULTRASOUND MEASURED FETUS HEAD
POSTERIOR FOSSA, STUDY OBSERVATION
(NARRATIVE)
ULTRASOUND MEASURED FETUS HEAD
THIRD VENTRICLE, STUDY OBSERVATION
ULTRASOUND MEASURED FETUS HEAD
THIRD VENTRICLE, STUDY OBSERVATION
(NARRATIVE)
UTERUS, FUNDAL HEIGHT (TAPE MEASURE)
Data
Type
Card
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
NM
0,1
TX
0,1
Response Code
or
Numeric Units
11881-0
NM
0,1
See LOINC RELMA HIPAA Table for full set of possible LOINC request codes.
Table 4.2.1 Copyright 1995-2003 Regenstrief Institute and the LOINC® Attachment Committee. All rights reserved.
4.3
Clinical Notes/Reports
4.3.1 Physician Hospital Discharge Summary (HOSP DISCH)
The rules for sending general and specific structures are the same as for the preceding tables.
Clinical Reports Attachments
V24AIM0004R010
26
Health Level Seven, Inc. © 1998-2002. All rights reserved
NPRM Draft
September 1, 2002
Table 4.3.1 - Physician Hospital Discharge Summary
LOINC code
11490-0
8656-1
8646-2
18841-7
8648-8
8649-6
8650-4
11535-2
8651-2
11544-4
18842-5
8653-8
10183-2
10184-0
10185-7
8655-3
11493-4
18776-5
11513-9
18771-6
18775-7
Short Name
PHYSICIAN HOSPITAL DISCHARGE
SUMMARY
HOSPITAL ADMISSION DATE
HOSPITAL ADMISSION DX
HOSPITAL CONSULTATIONS (NARRATIVE)
HOSPITAL COURSE (NARRATIVE)
HOSPITAL DISCHARGE DATE
HOSPITAL DISCHARGE DISPOSITION
(NARRATIVE)
HOSPITAL DISCHARGE DX (NARRATIVE)
HOSPITAL DISCHARGE DX
HOSPITAL DISCHARGE FOLLOWUP
(NARRATIVE)
HOSPITAL DISCHARGE HISTORY
(NARRATIVE)
HOSPITAL DISCHARGE INSTRUCTIONS TEXT
(NARRATIVE)
HOSPITAL DISCHARGE MEDICATIONS
(NARRATIVE)
HOSPITAL DISCHARGE PHYSICAL
(NARRATIVE)
HOSPITAL DISCHARGE PROCEDURES
(NARRATIVE)
HOSPITAL DISCHARGE PROCEDURES
HOSPITAL DISCHARGE STUDIES SUMMARY
(NARRATIVE)
TREATMENT PLAN, PLAN OF TREATMENT
(NARRATIVE)
PROVIDER SIGNING - IDENTIFIER
PROVIDER SIGNING - NAME
PROVIDER, STAFF PRACTITIONER
IDENTIFIER
Repeat identifier and name as a pair when multiple
staff practitioners are associated with the report.
PROVIDER, STAFF PRACTITIONER NAME
Data
Type
Card
Response Code
or
Numeric Units
0,1
TS
CE
TX
TX
TS
TX
0,1
0,1
0,1
0,1
0,1
0,1
TX
CE
TX
0,1
1,n
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
CE
TX
0,1
0,1
TX
0,1
CE
PN
CE
0,1
0,1
0,1
I9C
I9C
C4
NPI
NPI
18774-0
PN
0,1
See LOINC RELMA HIPAA Table for full set of possible LOINC request codes.
Table 4.3.1 Copyright 1995-2003 Regenstrief Institute and the LOINC® Attachment Committee. All rights reserved.
4.3.2 Operative Note (OP NOTE)
The rules for sending general and specific structures are the same as for the preceding tables.
Table 4.3.2 - Operative Note
LOINC code
11504-8
Short Name
Data
Type
Card
Response Code
or
Numeric Units
PROVIDER UNSPECIFIED OPERATIVE NOTE
Clinical Reports Attachments
V24AIM0004R010
27
Health Level Seven, Inc. © 1998-2002. All rights reserved
NPRM Draft
September 1, 2002
LOINC code
8723-9
10219-4
8720-5
10218-6
8719-7
10223-6
8729-6
10213-7
8722-1
10216-0
8717-1
18852-4
10221-0
10830-8
10217-8
10215-2
8724-7
10220-2
10214-5
8725-4
11513-9
18771-6
11531-1
18772-4
11532-9
18773-2
11489-2
18770-8
Short Name
DATE SURGERY
OPERATIVE NOTE - PREOPERATIVE DX
(NARRATIVE)
OPERATIVE NOTE - PREOPERATIVE DX
OPERATIVE NOTE - POSTOPERATIVE DX
(NARRATIVE
OPERATIVE NOTE - POSTOPERATIVE DX
OPERATIVE NOTE - SURGICAL PROCEDURE
(NARRATIVE)
OPERATIVE NOTE - SURGICAL PROCEDURE
OPERATIVE NOTE - ANESTHESIA
(NARRATIVE)
OPERATIVE NOTE - ANESTHESIA
OPERATIVE NOTE - FLUIDS
OPERATIVE NOTE - ESTIMATED BLOOD
LOSS VOL
OPERATIVE NOTE - SURGICAL DRAINS
(NARRATIVE)
OPERATIVE NOTE - SPECIMENS TAKEN
(NARRATIVE)
OPERATIVE NOTE - COMPLICATIONS
OPERATIVE NOTE - INDICATIONS
OPERATIVE NOTE - FINDINGS
OPERATIVE NOTE - SURGERY DESCRIPTION
OPERATIVE NOTE - PREP TIME DURATION
OPERATIVE NOTE - ANESTHESIA
DURATION
OPERATIVE NOTE - OPEN CLOSING
DURATION
PROVIDER SIGNING - IDENTIFIER
PROVIDER SIGNING - NAME
SURGEON RESIDENT - IDENTIFIER
SURGEON RESIDENT - NAME
SURGEON STAFF - IDENTIFIER
SURGEON STAFF - NAME
PROVIDER, DICTATING PRACTITIONER IDENTIFIER
PROVIDER, DICTATING PRACTITIONER NAME
Data
Type
Card
Response Code
or
Numeric Units
TS
TX
0,1
0,n
CE
TX
0,n
0,n
I9C
CE
TX
0,n
0,1
I9C
CE
TX
0,1
0,1
C4
CE
TX
NM
0,1
0,1
0,1
C4
TX
0,1
TX
0,1
TX
TX
TX
TX
NM
NM
0,n
0,n
0,1
0,1
0,1
0,1
NM
0,1
CE
PN
CE
PN
CE
PN
CE
0,1
0,1
0,1
0,1
0,1
0,1
0,1
PN
0,1
NPI
NPI
NPI
NPI
See LOINC RELMA HIPAA Table for full set of possible LOINC request codes.
Table 4.3.2 Copyright 1995-2003 Regenstrief Institute and the LOINC® Attachment Committee. All rights reserved.
4.3.3Provider Unspecified History and Physical Note
The rules for sending general and specific structures are the same as for the preceding tables.
Clinical Reports Attachments
V24AIM0004R010
28
Health Level Seven, Inc. © 1998-2002. All rights reserved
NPRM Draft
September 1, 2002
Table 4.3.3 - Provider Unspecified History & Physical Note
LOINC code
11492-6
10154-3
8674-4
8675-1
10164-2
11322-5
11320-9
11330-8
11287-0
11286-2
8658-7
11382-9
10156-8
11332-4
10157-6
10158-4
11334-0
11336-5
11369-6
10159-2
11338-1
10160-0
11340-7
10161-8
11342-3
11344-9
11346-4
11348-0
10162-6
11449-6
8678-5
8665-2
11350-6
29762-2
10166-7
8659-5
11294-6
11379-5
11380-3
10167-5
11366-2
8663-7
8664-5
10182-4
10187-3
10188-1
10171-7
Short Name
PROVIDER UNSPECIFIED HISTORY AND
PHYSICAL NOTE
CHIEF COMPLAINT
HISTORY SOURCE
HISTORY TAKER
HISTORY OF PRESENT ILLNESS
HISTORY OF GENERAL HEALTH
FEEDING AND DIETARY STATUS
HISTORY OF ALCOHOL USE
ALCOHOLIC DRINKS PER DRINKING DAY
ALCOHOL BINGE EPISODES
HISTORY OF ALLERGIES
MEDICATION ALLERGY
HISTORY OF CHILDHOOD DISEASES
HISTORY OF COGNITIVE FUNCTION
HISTORY OF FAMILY MEMBER DISEASES
HISTORY OF FUNCTIONAL STATUS
HISTORY OF GROWTH AND DEVELOPMENT
HISTORY OF HOSPITALIZATIONS
HISTORY OF IMMUNIZATION
HISTORY OF INDUSTRIAL EXPOSURE
HISTORY OF MAJOR ILLNESSES AND
INJURIES
HISTORY OF MEDICATION USE
HISTORY OF OCCUPATIONS
HISTORY OF OCCUPATIONAL EXPOSURE
HISTORY OF NONMEDICAL DRUG USE
HISTORY OF OTHER SOCIAL FACTORS
HISTORY OF OUTPATIENT VISITS
HISTORY OF PAST ILLNESS
HISTORY OF PREGNANCIES
PREGNANCY STATUS
MENSTRUAL STATUS
DATE LAST MENSTRUAL PERIOD
HISTORY OF SEXUAL BEHAVIOR
SOCIAL HISTORY
HISTORY OF SOCIAL FUNCTION
BIRTH CONTROL METHOD
CURRENT EMPLOYMENT
LEVEL OF EDUCATION
MARITAL STATUS AND LIVING
ARRANGEMENTS
HISTORY OF SURGICAL PROCEDURES
HISTORY OF TOBACCO USE
CIGARETTES SMOKED, CURRENT
(PACK/DAY)
CIGARETTES SMOKED, TOTAL (PACK/YR)
HISTORY OF TRAVEL
REVIEW OF SYSTEMS
REVIEW OF SYSTEMS OVERVIEW
EYES, HISTORY OF SYMPTOMS & DISEASES
Clinical Reports Attachments
V24AIM0004R010
Data
Type
Card
TX
CE
CE
TX
TX
TX
TX
NM
NM
CE
CE
TX
TX
TX
TX
TX
TX
TX
TX
TX
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
TX
TX
TX
TX
TX
TX
TX
TX
CE
CE
DT
TX
TX
TX
CE
TX
NM
TX
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,n
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
TX
TX
NM
0,1
0,1
0,1
NM
TX
TX
TX
TX
0,1
0,1
0,1
0,1
0,1
29
Health Level Seven, Inc. © 1998-2002. All rights reserved
Response Code
or
Numeric Units
NPRM Draft
September 1, 2002
LOINC code
10169-1
10174-1
10179-0
11354-8
10175-8
11353-0
10181-6
10178-2
11352-2
10165-9
10177-4
10168-3
10170-9
11355-5
11356-3
10176-6
11357-1
10172-5
10173-3
8672-8
10210-3
8716-3
10190-7
11451-2
10199-8
10197-2
10195-6
10203-8
11393-6
10201-2
11411-6
10207-9
Short Name
EARS, HISTORY OF SYMPTOMS & DISEASES
NOSE, HISTORY OF SYMPTOMS & DISEASES
THROAT & NECK, HISTORY OF SYMPTOMS
& DISEASES
EARS & NOSE & SINUSES & MOUTH &
THROAT, HISTORY OF SYMPTOMS &
DISEASES
ORAL CAVITY, HISTORY OF SYMPTOMS &
DISEASES
BREASTS, HISTORY OF SYMPTOMS &
DISEASES
URINARY TRACT, HISTORY OF SYMPTOMS
& DISEASES
SKIN, HISTORY OF SYMPTOMS & DISEASES
ALLERGIC & IMMUNOLOGIC, HISTORY OF
SYMPTOMS & DISEASES
HISTORY OF PSYCHIATRIC SYMPTOMS &
DISEASES
CARDIOVASCULAR SYSTEM, HISTORY OF
SYMPTOMS & DISEASES
RESPIRATORY SYSTEM, HISTORY OF
SYMPTOMS & DISEASES
ENDOCRINE SYSTEM, HISTORY OF
SYMPTOMS & DISEASES
GASTROINTESTINAL SYSTEM, HISTORY OF
SYMPTOMS & DISEASES
GENITOURINARY SYSTEMS, HISTORY OF
SYMPTOMS & DISEASES
REPRODUCTIVE SYSTEM, HISTORY OF
SYMPTOMS & DISEASES
INTEGUMENTARY SYSTEM, HISTORY OF
SYMPTOMS & DISEASES
HEMATOLOGIC SYSTEM, HISTORY OF
SYMPTOMS & DISEASES
MUSCULOSKELETAL SYSTEM, HISTORY OF
SYMPTOMS & DISEASES
NEUROLOGIC SYSTEM, HISTORY OF
SYMPTOMS & DISEASES
GENERAL STATUS PHYSICAL FINDINGS
VITAL SIGNS, PHYSICAL FINDINGS
MENTAL STATUS
PSYCHIATRIC FINDINGS
HEAD, PHYSICAL FINDINGS
EYE, PHYSICAL FINDINGS
EAR, PHYSICAL FINDINGS
NOSE, PHYSICAL FINDINGS
EARS & NOSE & MOUTH & THROAT,
PHYSICAL FINDINGS
MOUTH & THROAT & TEETH, PHYSICAL
FINDINGS
NECK, PHYSICAL FINDINGS
THORAX & LUNGS, PHYSICAL FINDINGS
Clinical Reports Attachments
V24AIM0004R010
Data
Type
Card
TX
TX
TX
0,1
0,1
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
TX
0,1
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
TX
TX
TX
TX
TX
TX
TX
TX
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
TX
0,1
TX
TX
0,1
0,1
30
Health Level Seven, Inc. © 1998-2002. All rights reserved
Response Code
or
Numeric Units
NPRM Draft
September 1, 2002
LOINC code
11391-0
11392-8
10200-4
10193-1
10192-3
10191-5
10204-6
11403-3
10198-0
11400-9
11401-7
11402-5
11388-6
10205-3
10196-4
11413-2
11387-8
11386-0
11394-4
11398-5
11415-7
11404-1
11406-6
11414-0
11407-4
11389-4
11385-2
11397-7
10209-5
10212-9
10211-1
10206-1
10194-9
10208-7
11384-5
11447-0
11390-2
11399-3
10202-0
11410-8
10186-5
11383-7
11450-4
Short Name
CHEST, PHYSICAL FINDINGS
CHEST WALL, PHYSICAL FINDINGS
HEART, PHYSICAL FINDINGS
BREASTS, PHYSICAL FINDINGS
BACK, PHYSICAL FINDINGS
ABDOMEN, PHYSICAL FINDINGS
PELVIS, PHYSICAL FINDINGS
GROIN, PHYSICAL FINDINGS
GENITOURINARY TRACT, PHYSICAL
FINDINGS
GENITALIA, PHYSICAL FINDINGS
GENITALIA FEMALE, PHYSICAL FINDINGS
GENITALIA MALE, PHYSICAL FINDINGS
BUTTOCKS, PHYSICAL FINDINGS
RECTUM, PHYSICAL FINDINGS
EXTREMITIES, PHYSICAL FINDINGS
SHOULDER, PHYSICAL FINDINGS
AXILLA, PHYSICAL FINDINGS
UPPER ARM, PHYSICAL FINDINGS
ELBOW, PHYSICAL FINDINGS
FOREARM, PHYSICAL FINDINGS
WRIST, PHYSICAL FINDINGS
HAND, PHYSICAL FINDINGS
HIP, PHYSICAL FINDINGS
THIGH, PHYSICAL FINDINGS
KNEE, PHYSICAL FINDINGS
CALF, PHYSICAL FINDINGS
ANKLE, PHYSICAL FINDINGS
FOOT, PHYSICAL FINDINGS
BALANCE+COORDINATION, PHYSICAL
FINDINGS
STRENGTH PHYSICAL FINDINGS
SENSATION, PHYSICAL FINDINGS
SKIN, PHYSICAL FINDINGS
DEEP TENDON REFLEXES, PHYSICAL
FINDINGS
VESSELS, PHYSICAL FINDINGS
PHYSICAL EXAMINATION BY ORGAN
SYSTEMS
HEMATOLOGIC+LYMPHATIC+IMMUNOLOG
IC PHYSICAL FINDINGS
CARDIOVASCULAR SYSTEM, PHYSICAL
FINDINGS
GASTROINTESTINAL SYSTEM, PHYSICAL
FINDINGS
NEUROLOGIC SYSTEM, PHYSICAL
FINDINGS
MUSCULOSKELETAL SYSTEM, PHYSICAL
FINDINGS
IDENTIFYING INFORMATION
PATIENT PROBLEM OUTCOME
PROBLEM LIST
Clinical Reports Attachments
V24AIM0004R010
Data
Type
Card
TX
TX
TX
TX
TX
TX
TX
TX
TX
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
0,1
TX
TX
TX
TX
0,1
0,1
0,1
0,1
TX
CE
0,1
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
0,1
TX
TX
CE
0,1
0,1
0,1
31
Health Level Seven, Inc. © 1998-2002. All rights reserved
Response Code
or
Numeric Units
NPRM Draft
September 1, 2002
LOINC code
Short Name
Data
Type
Card
18630-4
18776-5
PRIMARY DIAGNOSIS
CE
TREATMENT PLAN, PLAN OF TREATMENT
TX
(NARRATIVE)
11513-9
PROVIDER, SIGNING IDENTIFIER
CE
18771-6
PROVIDER, SIGNING NAME
PN
18775-7
PROVIDER, STAFF PRACTITIONER
CE
IDENTIFIER
18774-0
PROVIDER, STAFF PRACTITIONER NAME
PN
11489-2
PROVIDER, DICTATING PRACTITIONER CE
IDENTIFIER
18770-8
PROVIDER, DICTATING PRACTITIONER PN
NAME
See LOINC RELMA HIPAA Table for full set of possible LOINC request codes.
Response Code
or
Numeric Units
0,n
0,1
0,1
0,1
0,1
NPI
0,1
0,1
NPI
0,1
Table 4.3.3 Copyright 1995-2003 Regenstrief Institute and the LOINC® Attachment Committee. All rights reserved.
4.4
Radiology Studies
All radiology studies can be sent as a general or as a specific structure and they all use the same specific structure.
You can see these defined in the Relma HIPAA task. The following shows the specific structure for a small
sample of Radiology studies. Note that the structure is identical for all of these radiology reports. This radiology
specific structure is present under every radiology report code in RELMA.
4.4.1 Cervical Spine X-Ray
The rules for sending general and specific structures are the same as for the preceding tables.
Table 4.4.1 – Cervical Spine X-Ray
LOINC code
24946-6
18781-5
18780-7
18785-6
18779-9
18834-2
18782-3
19005-8
18783-1
11489-2
18770-8
Short Name
X-RAY CERVICAL SPINE STUDY
PROVIDER, ORDERING PRACTITIONER NAME
PROVIDER, ORDERING PRACTITIONER
IDENTIFIER
RADIOLOGY REASON FOR STUDY
RADIOLOGY COMPARISON STUDY - DATE
AND TIME
RADIOLOGY COMPARISON STUDY
OBSERVATION
RADIOLOGY - STUDY OBSERVATION
RADIOLOGY - IMPRESSION
RADIOLOGY STUDY - RECOMMENDATION
PROVIDER, DICTATING PRACTITIONER IDENTIFIER
PROVIDER, DICTATING PRACTITIONER NAME
PROVIDER SIGNING - NAME
PROVIDER SIGNING - IDENTIFIER
Data
Type
Card
PN
CE
0,1
0,1
TX
TS
0,1
0,1
TX
0,1
TX
TX
TX
CE
0,1
0,1
0,1
0,1
PN
0,1
Response Code
or
Numeric Units
NPI
NPI
18771-6
PN
0,1
11513-9
CE
0,1 NPI
Table 4.4.1 Copyright 1995-2003 Regenstrief Institute and the LOINC® Attachment Committee. All rights reserved.
Clinical Reports Attachments
V24AIM0004R010
32
Health Level Seven, Inc. © 1998-2002. All rights reserved
NPRM Draft
September 1, 2002
4.4.2 CT Study Head
The rules for sending general and specific structures are the same as for the preceding tables.
Table 4.4.2 – CT Study Head
LOINC code
11539-4
18781-5
18780-7
18785-6
18779-9
18834-2
18782-3
19005-8
18783-1
11489-2
18770-8
Short Name
CT HEAD STUDY
PROVIDER, ORDERING PRACTITIONER NAME
PROVIDER, ORDERING PRACTITIONER
IDENTIFIER
RADIOLOGY REASON FOR STUDY RADIOLOGY COMPARISON STUDY - DATE
AND TIME
RADIOLOGY COMPARISON STUDY OBSERVATION
RADIOLOGY - STUDY OBSERVATION
RADIOLOGY - IMPRESSION
RADIOLOGY STUDY - RECOMMENDATION
PROVIDER, DICTATING PRACTITIONER IDENTIFIER
PROVIDER, DICTATING PRACTITIONER NAME
PROVIDER SIGNING - NAME
PROVIDER SIGNING - IDENTIFIER
Data
Type
Card
PN
CE
0,1
0,1
TX
TS
0,1
0,1
TX
0,1
TX
TX
TX
CE
0,1
0,1
0,1
0,1
PN
0,1
Response Code
or
Numeric Units
NPI
NPI
18771-6
PN
0,1
11513-9
CE
0,1 NPI
Table 4.4.2 Copyright 1995-2003 Regenstrief Institute and the LOINC® Attachment Committee. All rights reserved
4.4.3 CT Study Extremity
The rules for sending general and specific structures are the same as for the preceding tables.
Table 4.4.3 - CT Study Extremity
LOINC code
24690-0
18781-5
18780-7
18785-6
18779-9
18834-2
18782-3
19005-8
18783-1
11489-2
18770-8
Short Name
CT EXTREMITY STUDY
PROVIDER, ORDERING PRACTITIONER NAME
PROVIDER, ORDERING PRACTITIONER
IDENTIFIER
RADIOLOGY REASON FOR STUDY RADIOLOGY COMPARISON STUDY - DATE
AND TIME
RADIOLOGY COMPARISON STUDY OBSERVATION
RADIOLOGY - STUDY OBSERVATION
RADIOLOGY - IMPRESSION
RADIOLOGY STUDY - RECOMMENDATION
PROVIDER, DICTATING PRACTITIONER IDENTIFIER
PROVIDER, DICTATING PRACTITIONER NAME
Clinical Reports Attachments
V24AIM0004R010
Data
Type
Card
PN
CE
0,1
0,1
TX
TS
0,1
0,1
TX
0,1
TX
TX
TX
CE
0,1
0,1
0,1
0,1
PN
0,1
33
Health Level Seven, Inc. © 1998-2002. All rights reserved
Response Code
or
Numeric Units
NPI
NPI
NPRM Draft
September 1, 2002
LOINC code
18771-6
11513-9
Short Name
PROVIDER SIGNING - NAME
PROVIDER SIGNING - IDENTIFIER
Data
Type
Card
PN
CE
0,1
0,1
Response Code
or
Numeric Units
NPI
Table 4.44.3 Copyright 1995-2003 Regenstrief Institute and the LOINC® Attachment Committee. All rights reserved.
4.4.4 MRI Study Head
The rules for sending general and specific structures are the same as for the preceding tables.
Table 4.4.4- MRI Study Head
LOINC code
11541-0
18781-5
18780-7
18785-6
18779-9
18834-2
18782-3
19005-8
18783-1
11489-2
18770-8
18771-6
11513-9
Short Name
MRI HEAD STUDY
PROVIDER, ORDERING PRACTITIONER NAME
PROVIDER, ORDERING PRACTITIONER
IDENTIFIER
RADIOLOGY REASON FOR STUDY
RADIOLOGY COMPARISON STUDY - DATE
AND TIME
RADIOLOGY COMPARISON STUDY OBSERVATION
RADIOLOGY - STUDY OBSERVATION
RADIOLOGY - IMPRESSION
RADIOLOGY STUDY - RECOMMENDATION
PROVIDER, DICTATING PRACTITIONER IDENTIFIER
PROVIDER, DICTATING PRACTITIONER NAME
PROVIDER SIGNING - NAME
PROVIDER SIGNING - IDENTIFIER
Data
Type
Card
PN
CE
0,1
0,1
TX
TS
0,1
0,1
TX
0,1
TX
TX
TX
CE
0,1
0,1
0,1
0,1
PN
0,1
PN
CE
0,1
0,1
Response Code
or
Numeric Units
NPI
NPI
NPI
Table4.4..4 Copyright 1995-2003 Regenstrief Institute and the LOINC® Attachment Committee. All rights reserved
4.4.5
Mammogram Screening Study
The rules for sending general and specific structures are the same as for the preceding tables.
Table 4.4.5- Mammogram Screening Study
LOINC code
24606-6
18781-5
18780-7
18785-6
18779-9
18834-2
Short Name
MAMMOGRAM SCREENING STUDY
PROVIDER, ORDERING PRACTITIONER NAME
PROVIDER, ORDERING PRACTITIONER
IDENTIFIER
RADIOLOGY REASON FOR STUDY
RADIOLOGY COMPARISON STUDY - DATE
AND TIME
RADIOLOGY COMPARISON STUDY OBSERVATION
Clinical Reports Attachments
V24AIM0004R010
Data
Type
Card
PN
CE
0,1
0,1
TX
TS
0,1
0,1
TX
0,1
34
Health Level Seven, Inc. © 1998-2002. All rights reserved
Response Code
or
Numeric Units
NPI
NPRM Draft
September 1, 2002
LOINC code
18782-3
19005-8
18783-1
11489-2
18770-8
18771-6
11513-9
Short Name
Data
Type
Card
TX
TX
TX
CE
0,1
0,1
0,1
0,1
PN
0,1
PN
CE
0,1
0,1
RADIOLOGY - STUDY OBSERVATION
RADIOLOGY - IMPRESSION
RADIOLOGY STUDY - RECOMMENDATION
PROVIDER, DICTATING PRACTITIONER IDENTIFIER
PROVIDER, DICTATING PRACTITIONER NAME
PROVIDER SIGNING - NAME
PROVIDER SIGNING - IDENTIFIER
Response Code
or
Numeric Units
NPI
NPI
Table 4.4.5Copyright 1995-2003 Regenstrief Institute and the LOINC® Attachment Committee. All rights reserved.
4.4.6 Nuclear Medicine Bone Scan Study
The rules for sending general and specific structures are the same as for the preceding tables.
Table 4.4.6- Nuclear Medicine Bone Scan Study
LOINC code
25031-6
18781-5
18780-7
18785-6
18779-9
18834-2
18782-3
19005-8
18783-1
11489-2
18770-8
Short Name
Data
Type
Card
PN
CE
0,1
0,1
TX
TS
0,1
0,1
TX
0,1
TX
TX
TX
CE
0,1
0,1
0,1
0,1
PN
0,1
NUCLEAR MEDICINE BONE SCAN STUDY
PROVIDER, ORDERING PRACTITIONER NAME
PROVIDER, ORDERING PRACTITIONER
IDENTIFIER
RADIOLOGY REASON FOR STUDY
RADIOLOGY COMPARISON STUDY - DATE
AND TIME
RADIOLOGY COMPARISON STUDY OBSERVATION
RADIOLOGY - STUDY OBSERVATION
RADIOLOGY - IMPRESSION
RADIOLOGY STUDY - RECOMMENDATION
PROVIDER, DICTATING PRACTITIONER IDENTIFIER
PROVIDER, DICTATING PRACTITIONER NAME
PROVIDER SIGNING - NAME
PROVIDER SIGNING - IDENTIFIER
Response Code
or
Numeric Units
NPI
NPI
18771-6
PN
0,1
11513-9
CE
0,1 NPI
Table 4.4.6Copyright 1995-2003 Regenstrief Institute and the LOINC® Attachment Committee. All rights reserved.
4.4.7 CT Guidance for Aspiration Study, Unspecified Site
The rules for sending general and specific structures are the same as for the preceding tables.
Table 4.4.7 - CT Guidance for Aspiration Study, Unspecified Site
LOINC code
Clinical Reports Attachments
V24AIM0004R010
Short Name
Data
Type
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Health Level Seven, Inc. © 1998-2002. All rights reserved
Card
Response Code
or
Numeric Units
NPRM Draft
September 1, 2002
LOINC code
25043-1
18781-5
18780-7
18785-6
18779-9
18834-2
18782-3
19005-8
18783-1
11489-2
18770-8
18771-6
11513-9
Short Name
CT GUIDANCE FOR ASPIRATION OF
UNSPECIFIED SITE STUDY
PROVIDER, ORDERING PRACTITIONER NAME
PROVIDER, ORDERING PRACTITIONER
IDENTIFIER
RADIOLOGY REASON FOR STUDY
RADIOLOGY COMPARISON STUDY - DATE
AND TIME
RADIOLOGY COMPARISON STUDY OBSERVATION
RADIOLOGY - STUDY OBSERVATION
RADIOLOGY - IMPRESSION
RADIOLOGY STUDY - RECOMMENDATION
PROVIDER, DICTATING PRACTITIONER IDENTIFIER
PROVIDER, DICTATING PRACTITIONER NAME
PROVIDER SIGNING - NAME
PROVIDER SIGNING - IDENTIFIER
Data
Type
Card
PN
CE
0,1
0,1
TX
TS
0,1
0,1
TX
0,1
TX
TX
TX
CE
0,1
0,1
0,1
0,1
PN
0,1
PN
CE
0,1
0,1
Response Code
or
Numeric Units
NPI
NPI
NPI
Table 4.4.7Copyright 1995-2003 Regenstrief Institute and the LOINC® Attachment Committee. All rights reserved.
4.4.8 Ultrasound Study of Neck
The rules for sending general and specific structures are the same as for the preceding tables.
Table 4.4.8- Ultrasound Study of Neck
LOINC code
24842-7
18781-5
18780-7
18785-6
18779-9
18834-2
18782-3
19005-8
18783-1
11489-2
18770-8
18771-6
11513-9
Short Name
ULTRASOUND NECK STUDY
PROVIDER, ORDERING PRACTITIONER NAME
PROVIDER, ORDERING PRACTITIONER
IDENTIFIER
RADIOLOGY REASON FOR STUDY
RADIOLOGY COMPARISON STUDY - DATE
AND TIME
RADIOLOGY COMPARISON STUDY OBSERVATION
RADIOLOGY - STUDY OBSERVATION
RADIOLOGY - IMPRESSION
RADIOLOGY STUDY - RECOMMENDATION
PROVIDER, DICTATING PRACTITIONER IDENTIFIER
PROVIDER, DICTATING PRACTITIONER NAME
PROVIDER SIGNING - NAME
PROVIDER SIGNING - IDENTIFIER
Data
Type
Card
PN
CE
0,1
0,1
TX
TS
0,1
0,1
TX
0,1
TX
TX
TX
CE
0,1
0,1
0,1
0,1
PN
0,1
PN
CE
0,1
0,1
Response Code
or
Numeric Units
NPI
NPI
NPI
Table 4.4.8Copyright 1995-2003 Regenstrief Institute and the LOINC® Attachment Committee. All rights reserved.
Clinical Reports Attachments
V24AIM0004R010
36
Health Level Seven, Inc. © 1998-2002. All rights reserved
NPRM Draft
September 1, 2002
5 Response Code Sets
This section describes response codes that may be used in in the computer-decision variant in the
<coded_entry.value> element to transmit a coded result or to send the units for a numerical result.
An entry in the value table refers to these code sets by a short abbreviation, such as “ans+”. These
abbreviations are used in the headings of the subsections of this section.
The values for some code sets appear directly in this document. In other cases, the section cites
another document as the source.
5.1
ans+: Extended ANSI Units Codes
ANSI X3.50-1986 and extensions as defined in HL7 Version 2.4, Figure 7-13.
5.2
C4: CPT-4
Procedure coding from American Medical Association, P.O. Box 10946, Chicago IL 60610.
5.3
HL70103: Processing ID
Description of whether HL7 messages represent production, testing, or training transactions.
5.4
I9C: ICD-9-CM
International Classification of Diseases, Clinical Modification.
5.5
iso+: Extended ISO Units Codes
ISO 2955-1983 and extensions as defined in HL7 Version 2.4 Figure 7-13.
5.6
NPI: National Provider ID
The NPI is a proposal to meet HIPAA requirements for a national standard to identify providers.
The Secretary DHHS has published a notice of proposed rule making (NPRM) specific to the NPI
and the public comment period has closed. An NPI final rule is being drafted and will, at some
point, be published in the Federal Register. For more information contact the US Department of
Health and Human Services, Centers for Medicaire and Medicaid Services (CMS), 7500 Security
Blvd., Baltimore, MD 21244.
The HHS Administration web site address is http://aspe.hhs.gov/admnsimp/.
Clinical Reports Attachments
V24AIM0004R010
37
Health Level Seven, Inc. © 1998-2002. All rights reserved
NPRM Draft
September 1, 2002