Drug Prior Authorization Attachment AIS

CDAR1AIS0010R010

Additional Information Specification 0010:

Drug Prior Authorization Attachment

Release 1.0

Based on HL7 CDA Standard Release 1.0, with supporting LOINC

®

Tables

Draft -

December 2006

Copyright © 1998-2005 Health Level Seven. All Rights Reserved.

Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010

This page intentionally blank

Page ii

November

2005

Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved.

Release 1.0 Draft Standard

Additional Information Specification 0010: PharmPA Attachment

Table of Contents

CDAR1AIS0010R010

1 INTRODUCTION ............................................................................................................................................... 1

1.1

LOINC C ODES AND S TRUCTURE ..................................................................................................................... 2

1.2

R EVISION H ISTORY .......................................................................................................................................... 4

1.3

P RIVACY C ONCERNS IN E XAMPLES .................................................................................................................. 4

1.4

HL7 A TTACHMENT -CDA D OCUMENT V ARIANTS ............................................................................................ 4

1.5

R EQUEST FOR I NFORMATION VERSUS R EQUEST FOR S ERVICE ......................................................................... 4

2 LOINC CODES ................................................................................................................................................... 5

2.1

S UPPORTING D OCUMENTATION ....................................................................................................................... 5

2.2

S COPE M ODIFICATION C ODES .......................................................................................................................... 5

2.3

S PECIAL C ONSIDERATIONS .............................................................................................................................. 5

2.4

A TTACHMENT D ATA C OMPONENTS ................................................................................................................. 6

2.4.1

Drug Request - Unspecified Therapeutic Category Attachment ............................................................ 6

2.4.2

NSAIDS - COX2 Inhibitors Attachment ............................................................................................... 6

2.4.3

Growth Hormone Attachment ............................................................................................................... 6

2.4.4

Proton Pump Inhibitors Attachment ...................................................................................................... 7

2.4.5

Erectile Dysfunction (ED) Agents Attachment ..................................................................................... 7

2.4.6

Narcotic (OPIOID) Agonists Attachment .............................................................................................. 8

2.4.7

Imidazole - Related Antifungals Attachment ........................................................................................ 8

3 DRUG PRIOR AUTHORIZATION ATTACHMENT VALUE TABLES .................................................... 8

3.1

D RUG R EQUEST U NSPECIFIED T HERAPEUTIC C ATEGORY (UTC) S ERVICE V ALUE T ABLE ............................. 9

3.2

NSAIDS COX2 I NHIBITORS V ALUE T ABLE ................................................................................................ 12

3.3

G ROWTH H ORMONE (GH) V ALUE T ABLE ...................................................................................................... 15

3.4

P ROTON P UMP I NHIBITORS (PPI) V ALUE T ABLE ............................................................................................ 23

3.5

E RECTILE D YSFUNCTION (ED) A GENTS V ALUE T ABLE ................................................................................. 27

3.6

N ARCOTIC (O PIOID ) A GONISTS V ALUE T ABLE ............................................................................................... 32

3.7

I MIDAZOLE R ELATED A NTIFUNGALS V ALUE T ABLE ................................................................................... 37

4 CODING EXAMPLES ..................................................................................................................................... 43

4.1

S CENARIO ...................................................................................................................................................... 43

4.1.1

Drug Prior Authorization Attachment, Human-Decision Variant (XML body) .................................. 44

4.1.2

Drug Prior Authorization Attachment, Human-Decision Variant (non-XML body) ........................... 49

4.1.3

Coded Drug Prior Authorization Attachment, Computer-Decision Variant ........................................ 52

5 RESPONSE CODE SETS ................................................................................................................................. 58

5.1

HL70136: Y ES -N O I NDICATOR ..................................................................................................................... 58

5.2

HL79038: D RUG P RESCRIBED , T HERAPY T YPE ............................................................................................. 58

5.3

HL79039: UTC, D IAGNOSIS C ONFIRMED B Y ............................................................................................... 58

5.4

HL79040: R EASON P RIOR T HERAPY D ISCONTINUED .................................................................................... 59

5.5

HL79041: NSAIDS/PPI R ELATED C ONCURRENT T HERAPY , T YPE ............................................................... 59

5.6

HL79042: NSAID U SE , D URATION .............................................................................................................. 59

5.7

HL79043: Y ES -N O -U NKNOWN I NDICATOR ................................................................................................... 59

5.8

HL79044: R ADIOLOGY D IAGNOSIS C ONFIRMATION , S TUDY T YPE ................................................................ 60

5.9

HL79045: L ABORATORY D IAGNOSIS C ONFIRMATION , S TUDY /T EST ............................................................ 60

5.10

HL79046: GH, P ATIENT H ISTORY

–

D OCUMENTED O NSET ...................................................................... 60

5.11

HL79047: GH, P ATIENT H ISTORY I NFORMATION

– H YPOTHALMIC P ITUITARY D ISEASE I NDUCED B Y .... 60

5.12

HL79048: T REATMENT S TATUS ............................................................................................................... 61

5.13

HL79049: GHD C HILDHOOD I NFORMATION , P UBERTY S TATUS .............................................................. 61

5.14

HL79050: GH D YSFUNCTION A DULT I NFORMATION , S ECONDARY C AUSES ............................................ 61

5.15

HL79051: N UTRITIONAL I NFORMATION , A SSESSMENT I NDICATOR ......................................................... 61

5.16

HL79052: P ARENTAL H EIGHT , A VAILABILITY I NDICATOR ...................................................................... 61



Page iii

November

2005


5.17

HL79053: D IAGNOSIS C ONFIRMATION AND L EVEL OF T REATMENT N EEDED , P ROCEDURE E MPLOYED ...62

5.18

HL79054: D IAGNOSIS C ONFIRMATION AND L EVEL OF T REATMENT N EEDED , GERD B Y E NDOSCOPY

T YPE 62

5.19

HL79055: H-P YLORI I NFORMATION , S TATUS ...........................................................................................62

5.20

HL79056: H-P YLORI I NFORMATION , C ONFIRMED B Y ..............................................................................62

5.21

HL79057: ED, R ELATED D IAGNOSIS C ONFIRMATION , C ONFIRMED B Y ...................................................63

5.22

HL79058: ED, P ATIENT H ISTORY

–

P ULMONARY H YPERTENSION F UNCTIONAL L EVEL ..........................63

5.23


– E VALUATION T YPE ..........................................................................63

5.24


– ED R ELATED T O ..............................................................................63

5.25

HL79061: ED, T REATMENT OF R ELATED C AUSES

– P SYCHOGENIC C AUSES OF ED T REATMENT ............64

5.26

HL79062: ED, T REATMENT OF R ELATED C AUSES

–

D RUG I NDUCED O PTION ..........................................64

5.27

HL79063: ED C ONCURRENT T HERAPY , T YPE ..........................................................................................64

5.28

HL79064: N ARCOTIC (O PIOID ) A GONISTS , P ATIENT H ISTORY

– P AIN S YNDROME S OURCE .....................64

5.29


– P AIN S YNDROME H ISTORY ...................65

5.30


– P AIN S YNDROME P ERSISTENCE .............65

5.31

HL79067: N ARCOTIC (O PIOID ) A GONISTS , C OMPLICATING C ONDITIONS ................................................65

5.32

HL79068: O PIOID R ELATED C ONCURRENT P AIN T HERAPY , O PIOID L EVEL .............................................65

5.33

HL79069: D RUG P RESCRIBED , T OPICAL T HERAPY R EASON ..................................................................66

5.34

HL79070: I MIDAZOLE

– R ELATED A NTIFUNGALS , D IAGNOSIS C ONFIRMED B Y .......................................66

5.35

HL79071: F UNGAL I NFECTION I NFORMATION , L OCATION .......................................................................66

5.36

HL79072: I MMUNE C OMPROMISE I NFORMATION , C AUSE ........................................................................66

5.37

HL79073: I MMUNE C OMPROMISE I NFORMATION , V ERIFIED B Y ..............................................................66

5.38

HL79074: C O -M ORBID C ONDITION I NFORMATION , L IVER D YSFUNCTION

–

C ONFIRMED B Y ..................67

5.39

HL79075: L EVEL OF F UNCTIONAL I MPAIRMENT ......................................................................................67

5.40

HL79076: I MIDAZOLE

– R ELATED A NTIFUNGALS , P RIOR T HERAPY T YPE ...............................................67

5.41

I9C : ICD-9-CM ........................................................................................................................................67

5.42

IC10: ICD-10-CM ....................................................................................................................................67

5.43

ISO +: E XTENDED ISO U NITS C ODES ..........................................................................................................68

5.44

NDC: N ATIONAL D RUG C ODE ..................................................................................................................68

5.45

RXNC: R X N ORM SCD (S EMANTIC C LINICAL D RUG ) ...............................................................................68

5.46

RXNB: R X N ORM SBD (S EMANTIC B RANDED D RUG ) ..............................................................................68

5.47

DEA: D RUG E NFORCEMENT A DMINISTRATION .........................................................................................68

5.48

HCI: HCI DEA ............................................................................................................................................69

5.49

NPI: N ATIONAL P ROVIDER I DENTIFIER .....................................................................................................69

5.50

PTX: H EALTH C ARE P ROVIDER T AXONOMY .............................................................................................70

5.51

M ISCELLANEOUS OID R EFERENCES ..........................................................................................................70

5.51.1

Unique Instance Identifier ....................................................................................................................70

5.51.2

person_name.type_cd ...........................................................................................................................70

5.51.3

Proprietary Provider ID ........................................................................................................................70

5.51.4

Example OID .......................................................................................................................................70

Page iv

November

2005




Index of Tables and Figures

Table 1.1 Relationship of LOINC Codes, X12N Transactions, and HL7 CDA Documents. ........................................ 3

Table 2.1 LOINC codes for a complete Drug Prior Authorization attachment data set ................................................ 5

Table 2.4.1 Data Components for Drug Request - Unspecified Therapeutic Category (UTC) Attachment .................. 6

Table 2.4.2 Data Components for NSAIDS - COX2 Inhibitors Attachment ................................................................. 6

Table 2.4.3 Data Components for Growth Hormone (GH) Attachment ........................................................................ 6

Table 2.4.4 Data Components for Proton Pump Inhibitors (PPI) Attachment ............................................................... 7

Table 2.4.5 Data Components for Erectile Dysfunction Agents Attachment ................................................................ 7

Table 2.4.6 Data Components for Narcotic Agonists Attachment ................................................................................ 8

Table 2.4.7 Data Components for Imidazole - Related Antifungals Attachment .......................................................... 8

Table 3.1 Drug Request - Unspecified Therapeutic Category Value Table .................................................................. 9

Table 3.2 NSAIDS - COX2 Inhibitors Value Table .................................................................................................... 12

Table 3.3 Growth Hormone Value Table .................................................................................................................... 15

Table 3.4 Proton Pump Inhibitors Value Table ........................................................................................................... 23

Table 3.5 Erectile Dysfunction Agents Value Table ................................................................................................... 27

Table 3.6 Narcotic(Opioid) Agonists Value Table ...................................................................................................... 32

Table 3.7 Imidazole - Related Antifungals Value Table ............................................................................................. 37

Figure 4.1 Drug Prior Authorization Additional Data ................................................................................................. 43

Example 4.1.1 Drug Prior Authorization Attachment, Human-Decision Variant (XML body) .................................. 44

Figure 1. Rendered Human-Decision Variant (XML body) ........................................................................................ 46

Example 4.1.2 Drug Prior Authorization Attachment, Human-Decision Variant (non-XML body)........................... 49

Figure 2. Rendered Human-Decision Variant (non-XML body) ................................................................................. 50

Example 4.1.2 Drug Prior Authorization Attachment, Computer-Decision Variant ................................................... 52

Figure 3. Rendered Human-Decision Variant (non-XML body) ................................................................................. 56

Table 5.1 Yes-No Indicator ......................................................................................................................................... 58

Table 5.2 Drug Prescribed, Therapy Type ................................................................................................................... 58

Table 5.3 UTC, Diagnosis Confirmed By .................................................................................................................. 58

Table 5.4 Reason Prior Therapy Discontinued ............................................................................................................ 59

Table 5.5 NSAIDS – COX 2 Inhibitors, Concurrent Therapy - Type ......................................................................... 59

Table 5.6 NSAID Use, Duration ................................................................................................................................. 59

Table 5.7 HL7 NSAID Use, Duration ........................................................................................................................ 59

Table 5.8 Radiology Diagnosis Confirmation, Study Type ......................................................................................... 60

Table 5.9 Laboratory Diagnosis Confirmation, Study/Test ......................................................................................... 60

Table 5.10 GH, Patient History – Documented Onset ................................................................................................. 60

Table 5.11 GH, Patient History Information – Hypothalmic Pituitary Disease Induced By ....................................... 60

Table 5.12 Treatment Status ........................................................................................................................................ 61

Table 5.13 GHD Childhood Information, Puberty Status............................................................................................ 61

Table 5.14 GH Dysfunction Adult Information, Secondary Causes ............................................................................ 61

Table 5.15 Nutritional Information, Assessment Indicator ......................................................................................... 61

Table 5.16 Parental Height, Availability Indicator ...................................................................................................... 62

Table 5.17 Diagnosis Confirmation and Level Treatment Needed, Procedure Employed .......................................... 62

Table 5.18 Diagnosis Confirmation and Level of Treatment Needed, GERD By Endoscopy Type ........................... 62

Table 5.19 H-Pylori Information, Status ..................................................................................................................... 62

Table 5.20 H-Pylori Information, Confirmed By ........................................................................................................ 62

Table 5.21 ED, Related Diagnosis Confirmation, Confirmed By ............................................................................... 63

Table 5.22 ED, Patient History – Pulmonary Hypertension Functional Level ............................................................ 63

Table 5.23 ED, Patient History – Evaluation Type ..................................................................................................... 63

Table 5.24 ED, Patient History – ED Related To ........................................................................................................ 63

Table 5.25 ED, Treatment of Related Causes – Psychogenic Causes of ED Treatment ............................................. 64

Table 5.26 ED, Treatment of Related Causes – Drug Induced Option ........................................................................ 64

Table 5.27 ED Concurrent Therapy, Type .................................................................................................................. 64

Table 5.28 Narcotic (Opioid) Agonists, Patient History – Pain Syndrome Source ..................................................... 64

Table 5.29 Narcotic (Opioid) Agonists, Patient History – Pain Syndrome History .................................................... 65

Table 5.30 Narcotic (Opioid) Agonists, Patient History – Pain Syndrome Persistance .............................................. 65

Table 5.31 Narcotic (Opioid) Agonists, Complicating Conditions ............................................................................. 65



Page v

November

2005


Table 5.32 Opioid Concurrent Pain Therapy, Opioid Level ........................................................................................65

Table 5.33 Drug Prescribed, Topical Therapy - Reason ..............................................................................................66

Table 5.34 Imidazole – Related Antifungals, Diagnosis Confirmed By ......................................................................66

Table 5.35 Fungal Infection Information, Location .....................................................................................................66

Table 5.36 Immune Compromise Information, Cause .................................................................................................66

Table 5.37 Immune Compromise Information, Verified By ........................................................................................66

Table 5.38 Co-Morbid Condition Information, Liver Dysfunction – Confirmed By ..................................................67

Table 5.39 Level of Functional Impairment ................................................................................................................67

Table 5.40 Imidazole – Related Antifungals, Prior Therapy Type .............................................................................67

Page vi

November

2005




1 Introduction

This publication provides the LOINC® 1 code values specific to a Drug Prior Authorization attachment for the following applications.



Those codes that define the attachment or attachment components used in transactions such as those defined by the ASC X12N 278 (005010X215) Health Care Services Review

Response and the ASC X12N 275 (005010X215) Additional Information to Support a

Health Care Services Review Implementation Guides which are products of the insurance subcommittee, X12N, of Accredited Standards Committee X12.

2,3



All of the codes may be used in HL7 Clinical Document Architecture (CDA) documents designed for inclusion in the BIN segment of the 275 transaction as described in the HL7

Additional Information Specification Implementation Guide 4

The format of this document and the methods used to arrive at its contents are prescribed in the

HL7 Additional Information Specification Implementation Guide .

Additional Information Specification 0010: Drug Prior Authorization Attachment is designed to facilitate the transmission of information necessary to evaluate and support the medical necessity for a drug being ordered for a patient. As the deployment of e-Prescribing and Electronic Health

Records expands and the technology matures, it is anticipated that this AIS will become an integral part of a fully automated prescription, authorization and delivery process. Most health plans make use of a prior authorization process, either for specified classes of drugs or for atypical use of a drug. The attachment component specifications included represent the most commonly requested documentation requirements. These were developed in collaboration with the National Council for

Prescription Drug Programs (NCPDP), Work Group 11 Prescriber/Pharmacist Interface, Prior

Authorization Transfer Task Group. Additional components will be developed as the industry needs are assessed and defined.

Section 2 of this document defines the LOINC codes used to request Drug Prior Authorization attachments and the LOINC codes of each component in an attachment. Section 3 further describes each component of the Drug Prior Authorization attachment, the cardinality of the components and their answer parts, and the description, data types, codes, and units of each answer part.

Section 4 presents coding examples, with a narrative scenario, an XML example, and a display image of each example attachment using a popular browser. Section 5 further describes the code sets used in the response to each answer part of the attachment.

Note: All LOINC codes and descriptions are copyrighted by the Regenstrief Institute, with all rights reserved. See http://www.LOINC.org

.

1 LOINC

®

is a registered trademark of Regenstrief Institute and the LOINC Committee. The LOINC database and

LOINC Users’ Guide are copyright 1998-2005 Regenstrief Institute and the LOINC Committee and the LOINC database codes and names are available at no cost from http://www.LOINC.org

. 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, PMB 161, 5284 Randolph Rd., Rockville, MD 20852-2116. Phone: 800-972-4334. or 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

)



Page 1

November

2005


1.1 LOINC Codes and Structure

CDAR1AIS0010R010

LOINC codes are used for several purposes:



In the X12N 278 transaction set, LOINC codes identify the attachment or attachment components being requested to support a claim or encounter.



In the HL7 CDA document, LOINC codes are used to identify the attachment, the attachment components, and their answer parts. This is returned in the X12N 275 transaction set.



LOINC modifier codes may be used in the 278 transaction to further define the specificity of a request.

Page 2

November

2005




Table 1.1 Relationship of LOINC Codes, X12N Transactions, and HL7 CDA Documents.

X12N 278 HL7 CDA

Purpose of

Attachment

Health Care Services

Review Response

X12N 275

Additional

Information to

Support a Health

Care Services

Review

Provide controlled content for X12N 275 BIN segment

LOINC

Modifier

Codes

Used in the STC segment to limit the scope or time frame of a request for information. e.g.,

 Send information for up to 90 days before the related request.

Reiterated in the

STC segment

Not used in the CDA document

LOINC

Attachment

Identifier

LOINC

Attachment

Component

Used in the STC segment to request an attachment in its entirety, e.g.,

 Send the Proton Pump

Inhibitors Attachment.

Used in the STC segment to request a specific attachment component or part of a clinical report, .e.g.,

 Send the H-Pylori

Treatment Information

LOINC

Attachment

Component

Answer Part

Not used in the 278

Reiterated in the

STC segment

Used in the

<document_type_cd> element of the header

Reiterated in the

STC segment

Not used in the 275 except within the

CDA instance document in the

BIN segment.

Used in the computerdecision CDA variant in the

<caption_cd> element of a

<section> to identify the attachment component being provided, e.g.,

This is information regarding H-Pylori

Treatment.

Used in the computerdecision CDA variant in the

<caption_cd> element of a

<paragraph>, an <item> element within a <list> or a

<td> element within a

<table> to identify the answer part of an attachment component being provided, e.g.,

This is the patient’s current height.



Page 3

November

2005


1.2 Revision History

Date

Initial Release for

Review

First Ballot

December 2005

March 2006

Purpose

CDAR1AIS0010R010

1.3 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 Additional Information Specification Implementation Guide , there are two variants of a CDA document when used as an attachment.

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 a "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, paragraphs, 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 specification for Drug Prior Authorization defines a “send-me-what-you-have” attachment. It asks for a set of Drug Prior Authorization attachment components needed for the

Drug Prior Authorization process. It is not asking for any additional data capture efforts . For example, if the request for data is to send the length of time the patient is expected to need the medication at the requested dose level, it is not asking the provider to obtain additional information if they don’t already have this information.

In any attachment component answer part it may sometimes be impossible to send a required answer and necessary to send, instead, a reason why the information is not available. In the human decision variant the sender shall supplement the natural language explanation of why the information is not available with local markup. In the computer-decision variant the sender shall

Page 4

November

2005



Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 include local markup to describe the reason that the information is not available as described in the

Data Types section of the HL7 Additional Information Specification Implementation

2 LOINC Codes

2.1 Supporting Documentation

Table 2.1 defines the LOINC codes used to request a complete attachment data set for Drug Prior

Authorization. The use of any of these codes in the 278 HI or PWK segments represents an explicit request for the complete set of data components relevant to the drug prior authorization.

The provider shall return all data components for which data is available.

The provider may choose to return images of pages that constitute the requested information by using the <non_xml> element of the CDA as described in the HL7 Additional Information

Specification Implementation Guide.

The set of data components for the Drug Prior Authorization attachment, identified by individual

LOINC codes, is defined in Section 2.4.

NOTE: The LOINC values represented in this draft ballot version are included as representative examples and are not the actual LOINC values that will be used for this attachment. Once the AIS has been approved, the actual LOINC values will be requested from Regenstrief and included in the final published version. The final check digit (after the hyphen) indicates for example purposes only, the specific drug attachment category. Where a component or answer part is re-used in the document, the sample LOINC value is repeated to indicate this re-use. The final check digit will be an “x” to indicate that it is used in more than one drug attachment category.

Table 2.1 LOINC codes for a complete Drug Prior Authorization attachment data set

LOINC code Attachment Name

99999-1

99999-2

99999-3

99999-4

99999-5

99999-6

99999-7

Drug Request – Unspecified Therapeutic Category Attachment

NSAIDS – COX2 Inhibitors Attachment

Growth Hormone Attachment

Proton Pump Inhibitors Attachment

Erectile Dysfunction Agents Attachment

Narcotic (Opioid) Agonists Attachment

Imidazole – Related Antifungals Attachment

2.2 Scope Modification Codes

The HL7 publication LOINC Modifier Codes (for use with ASC X12N Implementation Guides when

Requesting 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. This publication is available from HL7, and is in the download package with the AIS documents.

2.3 Special Considerations

Intentionally left blank.



Page 5

November

2005


2.4 Attachment Data Components

CDAR1AIS0010R010

Individual LOINC codes are defined for each data component of the attachment specific to the therapeutic drug category listed in Table 2.1. These LOINC codes are listed in sections 2.4.1 to

2.4.7 respectively. For example, the data components comprising the cardiac rehabilitation attachment (LOINC 18824-3) appear in Table 2.4.2. Each table is headed by the LOINC code defining the complete attachment.

The LOINC codes in Table 2.1 represent requests for complete Drug Prior Authorization attachments. However, the requester also has the option of focusing on a specific component of the attachment through the use of the LOINC codes defined in the following tables. In this case the provider will respond with information, where available, specific to the requested data components.

These LOINC codes may be used in ASC X12N 278 as defined in the associated Implementation

Guide and will be mirrored in the corresponding ASC X12N 275 response. In addition, these

LOINC codes are used in the <caption_cd> element of the computer-decision variant of HL7

Additional Information Specification Implementation Guide . The questions that these LOINC codes represent are the result of a significant industry outreach project and represent the complete set of

Drug Prior Authorization attachment components at this time. Additional drug therapeutic categories may be added to this document at a later date.

2.4.1 Drug Request - Unspecified Therapeutic Category Attachment

Table 2.4.1 Data Components for Drug Request - Unspecified Therapeutic Category (UTC)

Attachment

LOINC Code

99999-1

90010-x

90020-x

90030-x

90040-1

90050-1

90060-1

90070-x

90080-x

90090-x

Description

DRUG REQUEST - UNSPECIFIED THERAPEUTIC CATEGORY ATTACHMENT

PRESCRIBER INFORMATION (COMPOSITE)

PRESCRIBER CONTACT INFORMATION (COMPOSITE)

DRUG PRESCRIBED (COMPOSITE)

UTC, MEDICAL NECESSITY INFORMATION

UTC, RELATED DIAGNOSIS INFORMATION (COMPOSITE)

UTC, ADDITIONAL CONFIRMATION INFORMATION

MEDICARE ESRD CERTIFICATION DATE

DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS (COMPOSITE)

CONCURRENT THERAPY (COMPOSITE)

2.4.2 NSAIDS - COX2 Inhibitors Attachment

Table 2.4.2 Data Components for NSAIDS - COX2 Inhibitors Attachment

LOINC Code

99999-2

90010-x

90020-x

90030-x

90100-2

90080-x

90090-x

90110-x

90120-2

Description

NSAIDS - COX2 INHIBITORS ATTACHMENT




NSAIDS-COX2 INHIBITORS, RELATED DIAGNOSIS



NSAIDS/PPI RELATED CONCURRENT THERAPY (COMPOSITE)

NSAID USE (COMPOSITE)

2.4.3 Growth Hormone Attachment

Table 2.4.3 Data Components for Growth Hormone (GH) Attachment

Page 6

November

2005




LOINC Code

99999-3

90010-x

90020-x

90030-x

90130-3

90140-3

90150-3

90160-3

90170-3

90180-3

90190-3

90200-3

90210-3

90220-3

90230-3

90240-3

90250-3

90080-x

90090-x

CDAR1AIS0010R010

Description

GROWTH HORMONE ATTACHMENT




GH, RELATED DIAGNOSIS

RADIOLOGICAL DIAGNOSIS CONFIRMATION INFORMATION (COMPOSITE)

LABORATORY DIAGNOSIS CONFIRMATION INFORMATION (COMPOSITE)

GH, PATIENT HISTORY INFORMATION (COMPOSITE)

GHD CHILDHOOD INFORMATION (COMPOSITE)

GH DYSFUNCTIONADULT INFORMATION (COMPOSITE)

WASTING SYNDROME INFORMATION (COMPOSITE)

NUTRITIONAL INFORMATION (COMPOSITE)

LABORATORY GH STIMULATION (COMPOSITE)

PHYSICIAL FINDINGS, PATIENT HEIGHT (COMPOSITE)

PHYSICIAL FINDINGS, PATIENT WEIGHT (COMPOSITE)

PATIENT BODY MASS INDEX (COMPOSITE)

PARENTAL HEIGHT (COMPOSITE)



2.4.4 Proton Pump Inhibitors Attachment

Table 2.4.4 Data Components for Proton Pump Inhibitors (PPI) Attachment

LOINC Code

99999-4

90010-x

90020-x

90030-x

90260-4

90270-4

90280-4

90080-x

90090-x

90110-x

90290-4

90300-4

Description

PROTON PUMP INHIBITORS ATTACHMENT




PPI, RELATED DIAGNOSIS

DIAGNOSIS CONFIRMATION AND LEVEL OF TREATMENT NEEDED (COMPOSITE)

PPI, PATIENT HISTORY – STRICTURE PRESENT



NSAIDS/PPI RELATED CONCURRENT THERAPY (COMPOSITE)

H-PYLORI INFORMATION (COMPOSITE)

H-PYLORI TREATMENT (COMPOSITE)

2.4.5 Erectile Dysfunction (ED) Agents Attachment

Table 2.4.5 Data Components for Erectile Dysfunction Agents Attachment

LOINC Code

99999-5

90010-x

90020-x

90030-x

90310-5

90320-5

90330-5

90340-5

90080-x

90090-x

90340-5

Description

ERECTILE DYSFUNCTION AGENTS ATTACHMENT




ED, RELATED DIAGNOSIS

ED, RELATED DIAGNOSIS CONFIRMATION INFORMATION (COMPOSITE)

ED, PATIENT HISTORY INFORMATION (COMPOSITE)

ED, TREATMENT OF RELATED CAUSES (COMPOSITE)



ED RELATED CONCURRENT THERAPY (COMPOSITE)



Page 7

November

2005


2.4.6 Narcotic (OPIOID) Agonists Attachment

CDAR1AIS0010R010

Table 2.4.6 Data Components for Narcotic Agonists Attachment

LOINC Code

99999-6

90010-x

90020-x

90030-x

90360-6

90370-6

90380-6

90390-6

90080-x

90090-x

90400-6

90410-6

Description

NARCOTIC (OPIOID) AGONISTS ATTACHMENT




NARCOTIC (OPIOID) AGONISTS, RELATED DIAGNOSIS

NARCOTIC (OPIOID) AGONISTS, PATIENT HISTORY (COMPOSITE)

NARCOTIC (OPIOID) AGONISTS, COMPLICATING CONDITIONS INFORMATION

(COMPOSITE)

NARCOTIC (OPIOID) AGONISTS, LABORATORY INFORMATION (COMPOSITE)



OPIOD RELATED CONCURRENT PAIN THERAPY (COMPOSITE)

NARCOTIC (OPIOID) AGONISTS, USE FOR TREATMENT OF OPIOID ADDICTION

2.4.7 Imidazole - Related Antifungals Attachment

Table 2.4.7 Data Components for Imidazole - Related Antifungals Attachment

LOINC Code

99999-7

90010-x

90020-x

90030-x

90420-7

90430-7

90440-7

90450-7

90460-7

90070-x

90470-7

90480-7

90080-x

90490-7

90090-x

Description

IMIDAZOLE - RELATED ANTIFUNGALS ATTACHMENT




DRUG PRESCRIBED, TOPICAL THERAPY (COMPOSITE)

IMIDAZOLE - RELATED ANTIFUNGALS, RELATED DIAGNOSIS INFORMATION

(COMPOSITE)

FUNGAL INFECTION INFORMATION (COMPOSITE)

IMMUNE COMPROMISE INFORMATION (COMPOSITE)

CO-MORBID CONDITION INFORMATION (COMPOSITE)

MEDICARE ESRD CERTIFICATION DATE

LEVEL OF FUNCTIONAL IMPAIRMENT

INPATIENT TREATMENT INFORMATION (COMPOSITE)


IMIDAZOLE - RELATED ANTIFUNGALS, PRIOR THERAPY TYPE


3 Drug Prior Authorization Attachment Value Tables

Each of the tables in this section further describes the LOINC components listed in the above corresponding table, along with the expected answer part(s) for each question, including the data type, cardinality, and codes/units for each answer.

The minimum attachment data set equates to the required components; those identified in the value table, below, with cardinality (Card) of

{1,1} (component is required and has one and only one occurrence) or

{1,n} (component is required and has one or more occurrences).

Those data components 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.

Page 8

November

2005




3.1 Drug Request - Unspecified Therapeutic Category (UTC) Service Value

Table

Table 3.1 Drug Request - Unspecified Therapeutic Category Value Table

LOINC code

Component Answer

90010-x

Value

PRESCRIBER INFORMATION

Information about the practitioner prescribing the drug.

90011-x PRESCRIBER INFORMATION, NAME

This is the name of the practitioner prescribing the drug.

90012-x PRESCRIBER INFORMATION, IDENTIER

This may be repeated to convey multiple identifiers such as the

National Provider Identifier (NPI), Drug Enforcement Act number (DEA), Special DEA number, HCIdea Number or proprietary provider identifier.

Note: If the provider is a covered entity under HIPAA and the

NPI is mandated for use, the NPI must be sent as one of the

90020-x

90030-x identifiers and the legacy provider identifier must not be used.

90013-x PRESCRIBER INFORMATION, SPECIALTY TAXONOMY

CODE

This is the Taxonomy code that represents the medical specialty of the prescriber.

PRESCRIBER CONTACT INFORMATION

Contact information for the individual prescribing the drug.

90021-x PRESCRIBER CONTACT INFORMATION, PHONE

NUMBER

The phone number of the individual prescribing the drug.

90022-x PRESCRIBER CONTACT INFORMATION, FAX NUMBER

The fax number of the individual prescribing the drug.

DRUG PRESCRIBED

This is information about the drug requested in the prior authorization.

90031-x DRUG PRESCRIBED, NAME

This is the descriptive name of the drug prescribed.

90032-x DRUG PRESCRIBED, DRUG CODE

This is the code identifier for the drug prescribed as defined by

Representative NDC, RxNorm SCD or RxNorm SBD.

Data

Type

PN

CX

CE

TX

TX

TX

CE

Card Response Code

/ Numeric Units

1,1

1,1

1,n NPI

DEA

HCIdea

Proprietary

Provider ID

See note at left.

1,1 PTX

0,1

1,1

0,1

1,1

1,1

1,1 NDC

RxNorm SCD

RxNorm SBD



Page 9

November

2005


LOINC code


Value

90033-x DRUG PRESCRIBED, THERAPY TYPE

This is used to convey the historical use of the prescribed drug as part of the patient’s therapy.

INTRQ Initial Therapy

CNTRQ Continued Therapy

RPLRQ Replacement Therapy

ADDRQ Add on Therapy

90034-x DRUG PRESCRIBED, SELF ADMINISTERED INDICATOR

This indicator defines if the drug can be self administered.

90040-1

N No

Y Yes

UTC, MEDICAL NECESSITY INFORMATION

Additional information as required to support the medical necessity of the requested medication therapy. This is submitted

90040-1 based on the plan or UMO's defined requirements for the drug.

90050-1 UTC, RELATED DIAGNOSIS INFORMATION

Diagnosis information related to the prescribed drug.

90051-1 UTC, RELATED DIAGNOSIS

90060-1

This is the related diagnosis of the patient for which the drug is a prescribed therapy.

Note: Prior to U.S. adoption of ICD-10-CM, use ICD-9-CM in the U.S. domain. After adoption as the standard for defining diagnoses in the US, use only ICD-10-CM for requests in the

US.

90052-1 UTC, DIAGNOSIS CONFIRMED BY

This conveys the means by which the diagnosis was established- diagnostic procedures and/or clinical observation.

LABT Laboratory Examination

RADT Radiological Examination

OTDX Other Diagnostic Examination

CLNE Clinical Evaluation

90053-1 UTC, DIAGNOSIS CONFIRMED BY – DATE OF CLINICAL

EVALUATION

This is the date the confirmatory clinical evaluation was performed.

UTC, ADDITIONAL CONFIRMATION INFORMATION

This is used to convey information about the diagnostic study used to confirm the diagnosis. It is required when the answer to

Unspecified Therapeutic Category, Diagnosis Confirmed By is equal to “LABT” Laboratory Examination, “RADT”

Radiological Examination, or “OTDX” Other Diagnostic

Examination.

90061-1 UTC, ADDITIONAL CONFIRMATION INFORMATION -

NAME OF TEST

This is used to convey the name of the diagnostic study used to confirm the diagnosis.

Data

Type

CE

TX

CE

CE

DT

TX

Page 10

November

2005

CDAR1AIS0010R010


/ Numeric Units

1,1 HL79038

0,1 HL70136

0,1

1,1

1,1

1,1 IC9

IC10

0,n HL79039

01

0,n

0,1




LOINC code


Value



DATE OF TEST OR OBSERVATION

This is the date the confirmatory diagnostic study.

90070-x

90070-x

MEDICARE ESRD CERTIFICATION DATE

The date the patient was certified by Medicare as having End

Stage Renal Disease.

90080-x

TEST RESULT

This is the result of the diagnostic procedure by which the diagnosis was confirmed. It is required when the answer to

Unspecified Therapeutic Category, Diagnosis Confirmed By is equal to “LABT” Laboratory Examination

.

DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS

Information about other drugs previously prescribed for treatment of this condition with less than optimal outcomes.

90081-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS -

DRUG NAME

This is the descriptive name of the drug previously used to treat the diagnosis.

90082-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS, -

DRUG CODE

The code assigned to the drug previously used to treat the diagnosis as defined by: Representative NDC, RxNorm SCD, or RxNorm SBD.


DURATION OF THERAPY

Duration of previous therapy in days.


REASON PRIOR THERAPY DISCONTINUED

Reason prior drug therapy was discontinued.

NTEFF Not or No Longer Effective

SDEFT Side Effects/Tolerance

NTCMP Not Compatible

OTH Other


REASON PRIOR THERAPY DISCONTINUED, OTHER

If Drug History, Prior Therapy for Diagnosis - Reason Prior

Therapy Discontinued is equal to “OTH” Other, then this is required.

90086-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS –

REASON PRIOR THERAPY DISCONTINUED,

INCOMPATIBLE DRUG NAME

The descriptive name of the drug incompatible with the prior therapy. If Drug History, Prior Therapy for Diagnosis – Reason

Prior Therapy Discontinued equals “NTCMP” Not Compatible, then this is required.

Data

Type

NM

DT

DT

TX

CE

NM

CE

TX

TX

CDAR1AIS0010R010


/ Numeric Units

0,1 iso+ ans+

1,1

0,1

1,1

0,n

1,1

1,1 NDC

RxNorm SCD

RxNorm SBD

1,1 iso+

1,1 HL79040

0,1

0,n



Page 11

November

2005


LOINC code


90090-x

Value

CONCURRENT THERAPY

Drugs the patient is currently on, for this or other diagnoses, which may impact the requested drug.

90091-x CONCURRENT THERAPY, DRUG NAME

The descriptive name of the drug used in concurrent therapy, for this or other diagnoses, which may impact the requested drug.

90092-x CONCURRENT THERAPY, DRUG CODE

The code assigned to the concurrent drug as defined by:

Representative NDC, RxNorm SCD, or RxNorm SBD.

Data

Type

TX

CE

CDAR1AIS0010R010


/ Numeric Units

0,n

0,1

1,1 NDC

RxNorm SCD

RxNorm SBD

3.2 NSAIDS - COX2 Inhibitors Value Table

Table 3.2 NSAIDS - COX2 Inhibitors Value Table

LOINC code


90010-x

Value







National Provider Identifier (NPI), Drug Enforcement Act number (DEA), Special DEA number, HCIdea Number or proprietary provider identifier.


NPI is mandated for use, the NPI must be sent as one of the identifiers and the proprietary provider identifier must not be used.

90020-x

90030-x


CODE

This is the Taxonomy code that represents the medical specialty of the prescriber.




NUMBER

This is the phone number of the individual prescribing the drug.


This is the fax number of the individual prescribing the drug.

DRUG PRESCRIBED




Data

Type


/ Numeric Units

1,1

PN

CX

CE

TX

TX

TX

1,1

1,n NPI

DEA

HCIdea

Proprietary

Provider ID

See note at left.

1,1 PTX

0,1

1,1

0,1

1,1

1,1

Page 12

November

2005




LOINC code


Value


This is the code identifier for the drug prescribed as defined by

Representative NDC, Rx Norm SCD, or RxNorm SBD.









90100-2

90080-x

N No

Y Yes

NSAIDS-COX2 INHIBITORS, RELATED DIAGNOSIS


90100-2 NSAIDS-COX2 INHIBITORS, RELATED DIAGNOSIS



US.




DRUG NAME



DRUG CODE

The code assigned to the drug previously used to treat the diagnosis as defined by: Representative NDC, RxNorm SCD, or RxNorm SBD.

90083-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS,

DURATION OF THERAPY








OTH Other

Data

Type

CE

CE


/ Numeric Units

1,1 NDC

RxNorm SCD

RxNorm SBD

1,1 HL79038

CE

TX

CE

NM

CE

CDAR1AIS0010R010

0,1 HL70136

1,1

1,1 IC9

IC10

0,n

1,1

1,1 NDC

RxNorm SCD

RxNorm SBD

1,1 iso+

1,1 HL79040



Page 13

November

2005


LOINC code


Value



Description of the other reason for discontinued therapy. If

Drug History, Prior Therapy for Diagnosis - Reason Prior

Therapy Discontinued equals "OTH" Other, then this is required.


90090-x

REASON PRIOR THERAPY DISCONTINUED,







The descriptive name of the drug used in concurrent therapy, for this or other diagnoses, which may impact the requested drug.



Representative NDC, RxNorm SCD, or RxNorm SBD

90110-x

90120-x

NSAIDS/PPI RELATED CONCURRENT THERAPY

NSAID/PPI related drugs being used concurrently with the requested drug.

90111-x NSAIDS/PPI RELATED CONCURRENT THERAPY, TYPE

Concurrent NSAIDS/PPI related drug therapies being used for treatment of this or other conditions.

See section 5 for the list of valid codes.

90112-x NSAIDS/PPI RELATED CONCURRENT THERAPY,

OTHER TYPE

The descriptive name of the NSAIDS/PPI related drug(s) used in concurrent therapy. Required when NSAIDS/PPI Related

Concurrent Therapy, Type equals “OTH” Other.

NSAID USE

Extended NSAID use and associated problems.

90121-2 NSAID USE, DURATION

The length of time NSAID use is or has been required.

G21 NSAID use greater than 21 days

L21 NSAID use less than 21 days

90122-2 NSAID USE, INDUCED GI RISK FACTORS

Indicator of whether gastrointestinal risk factors are/have been induced by NSAID use.

Y Yes

N No

U Unknown

Data

Type

TX

TX

TX

CE

CE

TX

CE

CE

CDAR1AIS0010R010


/ Numeric Units

0,1

0,n

0,n

0,1

1,1 NDC

RxNorm SCD

RxNorm SBD

0,1

1,1 HL79041

0,1

1,1

1,1 HL79042

1,1 HL79043

Page 14

November

2005




3.3 Growth Hormone (GH) Value Table

CDAR1AIS0010R010

Table 3.3 Growth Hormone Value Table

LOINC code


90010-x

Value






This may be repeated to convey multiple identifications such as the National Provider Identifier (NPI0, the Drug Enforcement

Act (DEA) number, Special DEA number, HCIdea number or proprietary identifier.


NPI is mandated for use, the NPI must be sent as one of the identifiers and the legacy provider identifier must not be used.

90013-x PRESCRIBER INFORMATION, SPECIALITY TAXONOMY

90020-x

90030-x

CODE

This is the Taxonomy code that identifies the medical specialty of the prescriber




NUMBER




DRUG PRESCRIBED

This is information about the drug requested in the prior


This is the descriptive name of the drug prescribed. authorization.


This is the code identifier for the drug prescribed as defined by:

Representative NDC, RxNorm SCD or RxNorm SBD

Data

Type

PN

CX

CE

TX

TX

TX

CE


/ Numeric Units

1,1

1,1

1,n NPI

DEA

HCIdea

Proprietary

Provider ID

See note at left.

1,1 PTX

0,1

1,1

0,1

1,1

1,1

1,1 NDC

RxNorm SCD

RxNorm SBD



Page 15

November

2005


LOINC code


Value


This is used to convey the historical use of the prescribed drug as part of the patient's therapy.





90130-3



N No

Y Yes

GH, RELATED DIAGNOSIS


90130-3


US.

CE

CDAR1AIS0010R010

Data

Type

CE


/ Numeric Units

1,1 HL79038

0,1 HL70136

1,1

90140-3

1,1 IC9

IC10

0,n

90150-3

RADIOLOGICAL DIAGNOSIS CONFIRMATION

INFORMATION

Diagnostic procedures and criteria confirming the diagnosis and level of treatment need.

90141-3 RADIOLOGY DIAGNOSIS CONFIRMATION

INFORMATION, STUDY TYPE

These are the radiological studies used to confirm the diagnosis.

Epiphyseal status or bone age is required for childhood growth hormone deficiency..

BAE Bone Age

BDY Bone Density

MRI MRI

ESX X-Ray to Determine Epiphyseal Status

90142-3 RADIOLOGICAL DIAGNOSIS CONFIRMATION

INFORMATION, STUDY RESULT

Result of the radiological study performed. Required when diagnosis is confirmed by radiological study.

90143-3 RADIOLOGICAL DIAGNOSIS CONFIRMATION

INFORMATION, STUDY DATE

Date the radiological study performed. Required when diagnosis confirmed by radiological study.

LABORATORY DIAGNOSIS CONFIRMATION

INFORMATION

Diagnostic procedures and criteria confirming the diagnosis and level of treatment need.

CE

TX

DT

1,1 HL79044

1,1

1,1

0,n

Page 16

November

2005




LOINC code


Value

90151-3 LABORATORY DIAGNOSIS CONFIRMATION

INFORMATION, STUDY/TEST

These are laboratory studies used to confirm Growth Hormone

Deficiency/Dysfunction.

See section 5 for a list of valid codes.


90160-3

INFORMATION, OTHER STUDY/TEST NAME

This is used to convey the name of the other test used to confirm GHD. It is required when Diagnosis Confirmation

Information Laboratory Confirmation equals "OTH" Other.


INFORMATION, STUDY/TEST RESULT

This is the result of laboratory study used to confirm the diagnosis.


INFORMATION, STUDY/TEST DATE

This is the date that the test confirming the diagnosis of GHD was performed.

GH, PATIENT HISTORY INFORMATION

Patient history related to the prescribed drug.

90170-3

90161-3 GH, PATIENT HISTORY INFORMATION –

DOCUMENTED ONSET

Documented onset of hypothalamic pituitary disease or GH deficiency/dysfunction.

AO Adult Onset

CO Childhood Onset

UO Unknown Onset

90162-3 GH, PATIENT HISTORY INFORMATION –

HYPOTHALMIC PITUITARY DISEASE INDUCED BY

This describes conditions and/or treatments leading to HPD.

PTT Pituitary Tumor

IRR Irradiation

SUG Surgery

HMN Hormone Dysfunction or Therapy

TRA Trauma

90163-3 GH, PATIENT HISTORY INFORMATION – GHD

TREATMENT STATUS

This describes the treatment status, i.e., whether GH Therapy has been attempted in the past, is ongoing or is just begin.


90164-3 GROWTH HORMONE, PATIENT HISTORY

INFORMATION – GHD TREATMENT DATE

This is the date the current/most current GH treatment initiated/to be initiated.

GROWTH HORMONE DEFICIENCY (GHD)

CHILDHOOD INFORMATION

Information about growth hormone deficiency in childhood.



CDAR1AIS0010R010

Data

Type

CE


/ Numeric Units

1,n HL79045

TX

NM

DT

CE

CE

CE

DT

0,1

1,1 iso+ ans+

1,1

1,1

0,1 HL79046

0,n HL79047

1,1 HL79048

0,1

0,1

Page 17

November

2005


LOINC code


Value

90171-3 GHD CHILDHOOD INFORMATION, SMALL FOR

GESTATIONAL AGE INDICATOR

This conveys information about the size of the child at birth, if known.

N No

Y Yes

90172-3 GHD CHILDHOOD INFORMATION, PUBERTY STATUS

This information describes the status of the child relative to the onset of puberty if known.

BP Pre-pubertal

AP Post Pubertal

PS Pubertal

90173-3 GHD CHILDHOOD INFORMATION, THERAPY BY

PEDIATRIC ENDOCRINOLOGIST OR NEPHROLOGIST

INDICATOR

This conveys whether therapeutic intervention for the treatment of childhood GHD is recommended and managed by a Pediatric

Endocrinologist or Nephrologists.

90180-3

N No

Y Yes

GH DYSFUNCTION ADULT INFORMATION

This conveys information about Adult GH Dysfunction related to factors other than endocrine disorders

90181-3 GH DYSFUNCTION ADULT INFORMATION,

SECONDARY CAUSES

This conveys information about Adult GH Dysfunction related to factors other than endocrine disorders.

A Age

O Obesity

D Depression

OTH Other

90182-3 GHD DYSFUNCTION ADULT INFORMATION, OTHER

SECONDARY CAUSES

Description of the other causes of adult GH dysfunction.

Required when GH Dysfunction Adult, Secondary Causes

90190-3 equals "OTH" other.

WASTING SYNDROME INFORMATION

This provides information about the patient's concurrent

Wasting Syndrome

90191-3 WASTING SYNDROME INFORMATION, OCCURANCE

INDICATOR

This conveys whether the patient has a Wasting Syndrome in addition to the GHD.

N No

Y Yes

Data

Type

CE

CE

CE

CE

TX

CE

CDAR1AIS0010R010


/ Numeric Units

0,1 HL70136

1,1 HL79049

1,1 HL70136

0,1

1,n HL79050

0,1

1,1

1,1 HL70136

Page 18

November

2005




LOINC code


Value

90192-3 WASTING SYNDROME INFORMATION, WEIGHT LOSS

EQUAL TO OR GREATER THAN 10%

This conveys whether the patient has experienced unintentional weight loss equal to or greater than 10% of body mass.

N No

Y Yes

90193-3 WASTING SYNDROME INFORMATION, DUE TO

TREATABLE CONDITION INDICATOR

This defines whether the Wasting Syndrome is due to a treatable condition, e.g. an autoimmune disorder.

N No

Y Yes

90194-3 WASTING SYNDROME INFORMATION, TREATABLE

CONDITION STATUS INDICATOR

This indicates whether the treatable condition that is precipitating the Wasting Syndrome is being treated. Required if answer to Wasting Syndrome Information, Due to Treatable

Condition Indicator equals "Y" Yes.

N No

Y Yes

90200-3

90210-3

NUTRITIONAL INFORMATION

The information in this section is used to convey whether the nutritional intake, both quantity and variety, is a contributory factor in the GHD.

90201-3 NUTRITIONAL INFORMATION, ASSESSMENT

INDICATOR

This conveys whether there has been an assessment of the patient's diet and nutritional status. Information on nutritional assessment is required if patient has Wasting Syndrome.

CMP Completed

PLD Planned

90202-3 NUTRITIONAL INFORMATION, ASSESSMENT DATE

This is the date of scheduled or completed nutritional assessment.

90203-3 NUTRITIONAL INFORMATION, CONCURRENT

THERAPY INDICATOR

This is used to convey whether the patient is receiving nutritional counseling and treatment.

N No

Y Yes

LABORATORY GH STIMULATION

Provocative growth hormone stimulation, a minimum of 2 tests required.

90211-3 LABORATORY GH STIMULATION, AGENT NAME

This is the name of the stimulation agent used to induce GH release in the GH stimulation test.

CE

CE

CE

DT

CE

TX

CDAR1AIS0010R010

Data

Type

CE


/ Numeric Units

0,1 HL70136

0,1 HL70136

0,1 HL70136

0,1

0,1 HL79051

1,1

0,1 HL70136

1,n

1,1



Page 19

November

2005


LOINC code


Value

90212-3 LABORATORY GH STIMULATION, PEAK VALUES

This reports the peak values of GH activity achieved with

90220-3 provocative stimulation by named agent.

90213-3 LABORATORY GH STIMULATION, DATE

This is the date GH Stimulation testing was performed.

PHYSICAL FINDINGS, PATIENT HEIGHT

This is used to report the height of the patient as measured at named intervals.

90221-3 PHYSICAL FINDINGS, PATIENT HEIGHT AT BIRTH

This is the patient's height at birth or in the neonatal period.

Height will be reported in iso+ units of either cm

(centimeters) or in (inches).

90222-3 PHYSICAL FINDINGS, CURRENT PATIENT HEIGHT

This is the patient's height at the time of the request.



90223-3 PHYSICAL FINDINGS, CURRENT PATIENT HEIGHT -

DATE OF MEASUREMENT

This is the date that the current height measured

90224-3 PHYSICAL FINDINGS, BASELINE PATIENT HEIGHT

This is the baseline height measured at least six months prior to request for GH therapy. It is used for assessing growth rate before and after GH therapy



90225-3 PHYSICAL FINDINGS, BASELINE PATIENT HEIGHT -

DATE OF MEASUREMENT

This the date the baseline height was measured.

90226-3 PHYSICAL FINDINGS – PATIENT HEIGHT AT ONSET OF

TREATMENT

This is the patient height as measured immediately prior to treatment initiation. Required if Treatment has been initiated.



90227-3 PHYSICAL FINDINGS – PATIENT HEIGHT AT ONSET OF

TREATMENT – DATE OF MEASUREMENT

This is the date of measurement at or immediately prior to onset of treatment. Required if treatment has been initiated.

90228-3 PHYSICAL FINDINGS, PATIENT HEIGHT AT LAST

RENEWAL

This is the patient height as measured when GH therapy last requested.



Data

Type

NM

DT

NM

NM

DT

NM

DT

NM

DT

NM

CDAR1AIS0010R010


/ Numeric Units

1,n iso+ ans+

1,1

0,1

0,1 iso+ ans+

1,1 iso+ ans+

1,1

1,1 iso+ ans+

1,1

0,1 iso+ ans+

0,1

0,1 iso+ ans+

Page 20

November

2005




LOINC code


Value

90229-3 PHYSICAL FINDINGS, PATIENT HEIGHT AT LAST

RENEWAL, DATE OF MEASUREMENT

90230-3

This is the date the height was measured for the last request for renewal.

PHYSICAL FINDINGS, PATIENT WEIGHT

Weight of the patient at given intervals.

90231-3 PHYSICAL FINDINGS – PATIENT WEIGHT AT BIRTH

This is the weight of the patient at birth.

Weight will be reported as either iso+ units of gm (grams) or kg

(kilograms) or ans+ units of oz (ounces) or lb (pounds).

90232-3 PHYSICAL FINDINGS, CURRENT PATIENT WEIGHT

This is the weight of the patient as of the time of this request.



90233-3 PHYSICAL FINDINGS, CURRENT PATIENT WEIGHT -

DATE OF MEASUREMENT

This is the date the current weight was measured.

90234-3 PHYSICAL FINDINGS, BASELINE PATIENT WEIGHT

Baseline weight, at least six months prior to request for GH therapy.



90235-3 PHYSICAL FINDINGS, BASELINE PATIENT WEIGHT -

DATE OF MEASUREMENT

This is the date baseline weight was measured

90236-3 PHYSICAL FINDINGS, PATIENT WEIGHT AT ONSET OF

TREATMENT

This is the patient's weight as measured when treatment initiated. Required if treatment has been initiated.



90237-3 PHYSICAL FINDINGS, PATIENT WEIGHT AT ONSET OF

TREATMENT - DATE OF MEASUREMENT

This is the patient weight as measured at or immediately prior to the onset of treatment. Required if treatment has been initiated.

90238-3 PHYSICAL FINDINGS, PATIENT WEIGHT AT LAST

RENEWAL

This is the patient weight as measured when GH therapy was last requested.



90239-3 PHYSICAL FINDINGS, PATIENT WEIGHT LAST

RENEWAL - DATE OF MEASUREMENT

This is the date the patient weight was measured for the last renewal request.

Data

Type

DT

NM

NM

DT

NM

DT

NM

DT

NM

DT



CDAR1AIS0010R010


/ Numeric Units

0,1

0,1

0,1 iso+ ans+

1,1 iso+ ans+

1,1

1,1 iso+ ans+

1,1

0,1 iso+ ans+

0,1

0,1 iso+ ans+

0,1

Page 21

November

2005


LOINC code


90240-3

Value

PATIENT BODY MASS INDEX

This is information regarding the patient's body mass index.

90241-3 PATIENT BODY MASS INDEX, CURRENT

This the patient's Body Mass Index (BMI) as calculated at the time of the request

90250-3

Must be reported in iso+ units of IU (international units).

90242-3 PATIENT BODY MASS INDEX, AT ONSET OF

TREATMENT

This is the Body Mass Index as calculated at the time of onset of GH treatment.

Must be reported in iso+ units of IU (international units).

PARENTAL HEIGHT

Parental height information. May be required for coverage of childhood GH therapy.

90251-3 PARENTAL HEIGHT, AVAILABILITY INDICATOR

This reflects the availability of parental height information.

MK Mother Known

FK Father Known

BK Both Known

BU Both Unknown

90252-3 PARENTAL HEIGHT, MOTHER

Mother's height if known. Required if the Parental Height,

Availability Indicator equals "MK" mother known or "BK" both known.


90080-x


90253-3 PARENTAL HEIGHT, FATHER

Father's height if known. Required if the Parental Height,

Availability Indicator equals "FK" father known or "BK" both known.






DRUG NAME


90082-x DRUG HISTORY - PRIOR THERAPY FOR DIAGNOSIS, -

DRUG CODE

The code assigned to the drug previously used to treat the diagnosis as defined by: Representative NDC, RxNorm SCD or RxNorm SBD

Data

Type

NM

NM

CE

NM

NM

TX

CE

CDAR1AIS0010R010


/ Numeric Units

0,1

1,1 iso+

0,1 iso+

0,1

1,1 HL79052

0,1 iso+ ans+

0,1 iso+ ans+

0,n

1,1

1,1 NDC

RxNorm SCD

RxNorm SBD

Page 22

November

2005




LOINC code


Value


DURATION OF THERAPY




This is the reason that prior drug therapy was discontinued.




OTH Other


NAME OF INCOMPATIBLE DRUG(S)

The descriptive name of the drug Incompatible with the prior therapy. If Drug History, Prior Therapy for Diagnosis - Reason

Prior Therapy Discontinued equals "NTCMP" Not Compatible, then this is required.


REASON(S) PRIOR THERAPY DISCONTINUED, OTHER




90090-x CONCURRENT THERAPY

Drugs the patient is currently on, for this or other diagnoses, which might impact the requested drug.


The descriptive name of the drug(s) used in concurrent therapy, for this or other diagnoses, which may impact the requested drug.




CDAR1AIS0010R010

Data

Type

NM


/ Numeric Units

1,1 iso+

CE

TX

TX

TX

CE

1,1 HL79040

0,n

0,1

0,n

0,1

1,1 NDC

RxNorm SCD

RxNorm SBD

3.4 Proton Pump Inhibitors (PPI) Value Table

Table 3.4 Proton Pump Inhibitors Value Table

LOINC code

Component

Answer

90010-x

Value





Data

Type


/ Numeric Units

1,1

PN 1,1



Page 23

November

2005


LOINC code

Component

Answer

Value



DEA number, NPI, HCIdea Number or proprietary provider identifier.




CODE

This is the Taxonomy code that identifies the medical specialty of

90020-x

90030-x the prescriber



90021-x PRESCRIBER CONTACT INFORMATION, PHONE NUMBER




DRUG PRESCRIBED







.

Data

Type

CX

CE

TX

TX

TX

CE

CDAR1AIS0010R010


/ Numeric Units

1,n NPI

DEA

HCIdea

Proprietary

Provider ID

See note at left.

1,1 PTX

0,1

1,1

0,1

1,1

1,1

1,1 NDC

RxNorm SCD

RxNorm SBD

Page 24

November

2005




LOINC code

Component

Answer

Value








N No

90260-4

90270-4

Y Yes

PPI, RELATED DIAGNOSIS


Note: Prior to U.S. adoption of ICD-10-CM, use ICD-9-CM in the

U.S. domain. After adoption as the standard for defining

90260-4 diagnoses in the US, use only ICD-10-CM for requests in the US.

DIAGNOSIS CONFIRMATION AND LEVEL OF

TREATMENT NEEDED

Diagnosis procedures and criteria confirming the diagnosis and level of treatment needed.

90271-4 DIAGNOSIS CONFIRMATION AND LEVEL OF

TREATMENT NEEDED, PROCEDURE EMPLOYED

These are procedures performed to establish the diagnosis.

BMS Barium Studies

EGD Endoscopy

BIO Biopsy

90272-4 DIAGNOSIS CONFIRMATION AND LEVEL OF

TREATMENT NEEDED, GERD BY ENDOSCOPY TYPE

90280-4

This is the level of severity of GERD as confirmed by endoscopy.

Required when GERD confirmed by endoscopy.


PPI, PATIENT HISTORY - STRICTURE PRESENT

This conveys information that esophageal stricture is present with the related diagnosis. Required if the related diagnosis is "Barrett

90080-x

90280-4

Esophagus".

N No

Y Yes



Data

Type

CE

CE

CE

CE

CE

CE

CDAR1AIS0010R010


/ Numeric Units

1,1 HL79038

0,1 HL70136

1,1

1,1 IC9

IC10

1,1

1,n HL79053

0,1 HL79054

0,1

1,1 HL70136

0,n



Page 25

November

2005


LOINC code

Component

Answer

Value


DRUG NAME



DRUG CODE

The code assigned to the drug previously used to treat the diagnosis as defined by: Representative NDC, RxNorm SCD or

RxNorm SBD

90083-x DRUG HISTORY,PRIOR THERAPY FOR DIAGNOSIS -

DURATION OF THERAPY




This is the reason that the prior drug therapy was discontinued.




OTH Other


REASON(S) PRIOR THERAPY DISCONTINUED, OTHER

Description of the other reason for discontinued therapy. If Drug

History, Prior Therapy for Diagnosis - Reason Prior Therapy

Discontinued equals "OTH" Other, then this is required.


90090-x

90110-x



Therapy Discontinued equals "NTCMP" Not Compatible, then this is required.






The code assigned to the ordered drug as defined by:


NSAIDS/PPI RELATED CONCURRENT THERAPY

NSAID/PPI related drugs being used concurrently with the requested drug.

90111-x NSAIDS/PPI RELATEDE, CONCURRENT THERAPY, TYPE

Concurrent NSAIDS/PPI related drug therapies being used for treatment of this or other conditions.


CDAR1AIS0010R010

Data

Type


/ Numeric Units

TX 1,1

CE

NM

CE

TX

TX

TX

CE

CE

1,1 NDC

RxNorm SCD

RxNorm SBD

1,1 iso+

1,1 HL79040

0,1

0,n

0,n

0,1

1,1 NDC

RxNorm SCD

RxNorm SBD

0,1

1,1 HL79041

Page 26

November

2005




LOINC code

Component

Answer

Value

90112-x NSAIDS/PPI RELATED CONCURRENT THERAPY, OTHER

90290-4

TYPE

The descriptive name of the NSAIDS/PPI related drug(s) used in concurrent therapy. Required when NSAIDS/PPI Related

Concurrent Therapy, Type equals “OTH” Other.

H-PYLORI INFORMATION

H-Pylori status in relation to the need for PPI.

90300-4

90291-4 H-PYLORI INFORMATION, STATUS

This is the documented H-Pylori status of the patient.

PS Positive

NE Negative

90292-4 H-PYLORI INFORMATION, CONFIRMED BY

This conveys the method used to confirm H-Pylori.


90293-4 H-PYLORI INFORMATION, CONFIRMED BY - OTHER

Description of the method used to confirm the presence of H-

Pylori, required when the response to H-Pylori Information,

Confirmed by equals "OTH" Other.

H-PYLORI TREATMENT

H-Pylori treated or being treated.

90301-4 H-PYLORI TREATMENT, CDA PROTOCOL INDICATOR

This conveys whether the treatment of H-Pylori is/was/will be done in compliance with CDA protocols.

N No

Y Yes

90302-4 H-PYLORI TREATMENT, START DATE

This is the date that treatment of H-Pylori began or is to begin.

90303-4 H-PYLORI TREATMENT, END DATE

Date treatment of H-Pylori was or is expected to be completed.

CDAR1AIS0010R010

Data

Type


/ Numeric Units

TX 0,1

CE

CE

TX

0,1

1,1 HL79056

1,n HL79057

0,1

0,1

CE 1,1 HL70136

DT

DT

0,1

0,1

3.5 Erectile Dysfunction (ED) Agents Value Table

Table 3.5 Erectile Dysfunction Agents Value Table

LOINC code

Component

Answer

90010-x

Value





Data

Type

Card

1,1

Response

Code

/ Numeric Units

PN 1,1



Page 27

November

2005


LOINC code

Component

Answer

Value







CODE

This is the Taxonomy code that identifies the medical specialty of

90020-x

90030-x the prescriber.



90021-x PRESCRIBER CONTACT INFORMATION, PHONE NUMBER




DRUG PRESCRIBED







Data

Type

CX

CE

TX

TX

TX

CE

CDAR1AIS0010R010

Card Response

Code

/ Numeric Units

1,n NPI

DEA

HCIdea

Proprietary

Provider ID

See note at left.

1,1 PTX

0,1

1,1

0,1

1,1

1,1

1,1 NDC

RxNorm SCD

RxNorm SBD

Page 28

November

2005




LOINC code

Component

Answer

Value









N No

Y Yes

90310-5

90320-5

ERECTILE DYSFUNCTION, RELATED DIAGNOSIS


Note: Prior to U.S. adoption of ICD-10-CM, use ICD-9-CM in the

U.S. domain. After adoption as the standard for defining diagnoses in the US, use only ICD-10-CM for requests in the US.

90310-5

ED, RELATED DIAGNOSIS CONFIRMATION

INFORMATION

This is information about how the diagnosis was confirmed.

90330-5

90321-5 ED, RELATED DIAGNOSIS CONFIRMATION –

CONFIRMED BY

This reports tests used to confirm the ED diagnosis


90322-5 ED, RELATED DIAGNOSIS CONFIRMATION – ED

DIAGNOSIS CONFIRMED BY, OTHER

This is used to convey the name of the other test used to confirm

ED. It is required when Erectile Dysfunction, Patient History –

ED Diagnosis Confirmed By equals "OTH" Other.

90323-5 ED, RELATED DIAGNOSIS CONFIRMATION – RESULT

This is the result of the test confirming diagnosis of ED

90324-5 ED, RELATED DIAGNOSIS CONFIRMATION - DATE

This is the date that the test confirming diagnosis of ED was performed.

ED, PATIENT HISTORY INFORMATION

This is information relating to the history of the patient.

CE

CE

TX

CDAR1AIS0010R010

Data

Type

CE

Card Response

Code

/ Numeric Units

1,1 HL79038

0,1 HL70136

1,1

1,1 IC9

1,n

IC10

1,n HL79057

0,1

NM 1,1 iso+

DT 1,1

1,1



Page 29

November

2005


LOINC code

Component

Answer

Value

90331-5 ED, PATIENT HISTORY – PULMONARY HYPERTENSION

FUNCTIONAL LEVEL

Functional Level of Individual with Primary Pulmonary

Hypertension, Peripheral Artery Hypertension or Pulmonary

Artery Hypertension

C1 Class I

C2 Class II

C3 Class III

C4 Class IV

90332-5 ED, PATIENT HISTORY – EVALUATION TYPE

COMPLETED

This conveys whether the patient has been evaluated for general health or contributory factors.

GH General Health Status Evaluation

UC Investigation of Underlying Causes of Primary Condition

NA Not applicable

90333-5 ED, PATIENT HISTORY – ED LEVEL INDICATOR

This indicator defines whether the dysfunction is present 50% or more of the time in the last 6 months.

Y Yes

N No

90334-5 ED, PATIENT HISTORY – ED RELATED TO

This is used to convey information related to other conditions resulting in ED

90340-5


ED, TREATMENT OF RELATED CAUSES

Treatment status of conditions precipitating ED.

90341-5 ED, TREATMENT OF RELATED CAUSES – TREATMENT

OF REVERSIBLE CAUSES STATUS

Treatment status of conditions precipitating ED.


90342-5 ED, TREATMENT OF RELATED CAUSES – RADIATION

THERAPY STATUS

This is used to convey the status of Radiation Therapy, It is required if the related diagnosis is Testicular Cancer.


90343-5 ED, TREATMENT OF RELATED CAUSES – RADIATION

THERAPY START DATE

This is the date that radiation therapy began. It is required if radiation therapy is planned or in progress.

90344-5 ERECTILE DYSFUNCTION, TREATMENT OF RELATED

CAUSES – RADIATION THERAPY END DATE

This is the date that radiation therapy was or is expected to be completed. Required when Radiation Therapy employed for treatment.

Page 30

November

2005

Data

Type

CE

CE

CE

CE

CE

CE

DT

DT

CDAR1AIS0010R010

Card Response

Code

/ Numeric Units

0,1 HL79058

1,1 HL79059

1,1 HL70136

0,n HL79060

0,1

1,1 HL79048

0,1 HL79048

0,1

0,1




LOINC code

Component

Answer

Value

90345-5 ED, TREATMENT OF RELATED CAUSES – SURGICAL

TREATMENT INDICATOR

This conveys information about whether the related condition can or has been treated with surgery. It is required if the related diagnosis is Testicular Cancer.

CMP Completed

PLD Planned

90346-5 ED, TREATMENT OF RELATED CAUSES – SURGERY

DATE

This is the date that surgery was or is expected to be accomplished. Required when Surgery is employed for treatment of Testicular Cancer.

90347-5 ED, TREATMENT OF RELATED CAUSES – PSYCHOGENIC

CAUSES OF ED TREATMENT

This conveys information about whether the psychogenic components of ED can or have been treated and if so, by what method.

PSY Psychotherapy

BHT Behavior Therapy

OTT Other Therapy

NOT No Therapy

90348-5 ED, TREATMENT OF RELATED CAUSES – ED DRUG

INDUCED INDICATOR

This is used to convey whether the ED is secondary to drugs being taken by the patient.

90080-x

N No

Y Yes

90349-5 ED, TREATMENT OF RELATED CAUSES – DRUG

INDUCED OPTION

This is used to define the options, if any, for altering the use of drug that is precipitating ED.

RDU Reduction in Drug Use

DCT Discontinue Drug Use

CGD Change Drug

DCN Drug Cannot be Changed or Discontinued




DRUG NAME



DRUG CODE

The code assigned to the drug previously used to treat the diagnosis as defined by: Representative NDC, RxNorm SCD, or

RxNorm SBD

Data

Type

CE

DT

CE

CE

CE

TX

CE

CDAR1AIS0010R010

Card Response

Code

/ Numeric Units

0,1 HL79051

0,1

0,1 HL79061

0,1 HL70136

0,1 HL79062

0,n

1,1

1,1 NDC

RxNorm SCD

RxNorm SBD



Page 31

November

2005


LOINC code

Component

Answer

Value

90083-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS, -

DURATION OF THERAPY








OTH Other



90090-x

Description of the other reason for discontinued therapy. If Drug

History, Prior Therapy for Diagnosis - Reason Prior Therapy

Discontinued equals "OTH" Other, then this is required.


REASON PRIOR THERAPY DISCONTINUED, NAME OF

INCOMPATIBLE DRUG(S)

The descriptive name of the drug incompatible with the prior therapy. If Drug History, Prior Therapy for Diagnosis - Reason




90350-5




The code assigned to the concurrnt drug as defined by:


ED RELATED CONCURRENT THERAPY

ED related drugs being used concurrently with the requested drug.

90351-5 ED RELATED CONCURRENT THERAPY, TYPE

Concurrent ED related drug therapies being used for treatment of this or other conditions.


90352-5 ED RELATED CONCURRENT THERAPY, DRUG NAME(S)

The descriptive name of the ED related drug(s) used in concurrent therapy. Required when ED Related Concurrent Therapy, Type equals “OTH” Other.

Data

Type

Card Response

Code

/ Numeric Units

NM 1,1 iso+

CE

TX

TX

TX

CE

CE

TX

CDAR1AIS0010R010

1,1 HL79040

0,1

0,1

0,n

0,1

1,1 NDC

RxNorm SCD

0,1

RxNorm SBD

1,1 HL79063

0,1

3.6 Narcotic(Opioid) Agonists Value Table

Table 3.6 Narcotic(Opioid) Agonists Value Table

LOINC code


Value

Page 32

November

2005

Data

Type


/ Numeric Units




LOINC code


90010-x

Value





90020-x

90030-x







CODE

Taxonomy code that identifies the medical specialty of the prescriber




NUMBER




DRUG PRESCRIBED






Representative NDC, RxNorm SCD or RxNorm SBD.

Data

Type

PN

CX

CE

TX

TX

TX

CE

CDAR1AIS0010R010


/ Numeric Units

1,1

1,1

1,n NPI

DEA

HCIdea

Proprietary

Provider ID

See note at left.

1,1 PTX

0,1

1,1

0,1

1,1

1,1

1,1 NDC

RxNorm SCD

RxNorm SBD



Page 33

November

2005


LOINC code


Value







90360-6



N No

Y Yes

NARCOTIC (OPIOID) AGONISTS, RELATED

DIAGNOSIS



90360-6

US.

90370-6 NARCOTIC (OPIOID) AGONISTS, PATIENT HISTORY

Patient history related to the prescribed drug.

90371-6 NARCOTIC (OPIOID) AGONISTS, PATIENT HISTORY –

PAIN SYNDROME SOURCE

This conveys information regarding the source or type of pain the patient is experiencing.



PAIN SYNDROME SOURCE, OTHER

Description of the source of the Pain Syndrome. Required when the answer to Opioid Agonists, Patient History – Pain

Syndrome Source equals “OTH”, other.


PAIN SYNDROME FRENQUENCY

Frequency with which pain occurs.

CP Constant Pain

ITP Intermittent Pain

ICP Incidental Pain


PAIN SYNDROME PERSISTENCE

Anticipated duration/persistence of pain.

AL Acute Limited – less than 30 Days

CR Chronic

CRP Chronic Progressive

CPR Chronic Progressive with Escalating Opioid

Data

Type

CE

CE

CE

CE

TX

CE

CE

CDAR1AIS0010R010


/ Numeric Units

1,1 HL79038

0,1 HL70136

1,1

1,1 IC9

IC10

1,1

1,1 HL79064

0,1

1,1 HL79065

1,1 HL79066

Page 34

November

2005




LOINC code


90380-6

Value

NARCOTIC (OPIOID) AGONISTS, COMPLICATING

CONDITION INFORMATION

Information about co-morbid conditions complicating or exacerbating pain management.

90381-6 NARCOTIC (OPIOID) AGONISTS, COMPLICATING

CONDITIONS

Co-morbid conditions complicating or exacerbating pain management.


90382-6 NARCOTIC (OPIOID) AGONISTS, COMPLICATING

CONDITIONS, OTHER

Description of co-morbid condition. Required when answer to

Complicating Condition equals “OTH” Other.

90390-6 NARCOTIC (OPIOID) AGONISTS, LABORATORY

INFORMATION

Report of drug screens performed since last review or escalation of drug therapy.

90391-6 NARCOTIC (OPIOID) AGONISTS, LABORATORY –

NAME OF TEST

The name of the test used to verify the presence of the Opioid.

90392-6 NARCOTIC (OPIOID) AGONISTS, LABORATORY - DATE

OF TEST

Date test performed

90393-6 NARCOTIC (OPIOID) AGONISTS, LABORATORY – TEST

RESULT

This conveys the results of the drug screen.

90080-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS

Information about other drugs previously prescribed for pain management, both opioid and non-opioid, with less than optimal outcomes.


DRUG NAME

Name of drug previously used for pain management.


DRUG CODE



DURATION OF THERAPY


Data

Type

CE

TX

TX

DT

NM

TX

CE

NM

CDAR1AIS0010R010


/ Numeric Units

1,n

1,1 HL79067

0,1

1,n

1,1

1,1

1,1 iso+

0,n

1,1

1,1 NDC

RxNorm SCD

RxNorm SBD

1,1 iso+



Page 35

November

2005


LOINC code


Value



This is the reason that the prior pain therapy was discontinued.




OTH Other

90090-x




Drug History, Prior Therapy for Pain Management – Reason

Prior Therapy Discontinued equals “OTH” Other, then this is required.



The descriptive name of the drug Incompatible with the prior therapy. If Drug History, Prior Therapy for Diagnosis – Reason




90400-6

90410-6



90092-x CONCURRENT THERAPY – DRUG CODE



OPIOID RELATED CONCURRENT PAIN THERAPY

Concurrent drug therapies used in pain management.

90401-6 OPIOID RELATED CONCURRENT PAIN THERAPY,

NAME

Descriptive name of the Opioid and non-Opioid drugs used concurrently for pain management.


DRUG CODE


Representative NDC, RxNorm SCD, or RxNorm SBD .


OPIOID LEVEL

Level of concurrent Opioid therapy.

RDL Recommended Dose Level

HPL High Potency Dose Level

24L 24 Hour High Potency Dose Level

OTL Opioid Tolerant

NARCOTIC (OPIOID) AGONIST, USE FOR

TREATMENT OF OPIOID ADDICTION

Use of Narcotic (Opioid) Agonists for the treatment of opioid addiction.

Page 36

November

2005

Data

Type

CE

TX

TX

TX

CE

TX

CE

CE

CDAR1AIS0010R010


/ Numeric Units

1,1 HL9040

0,1

0,1

0,1

0,1

1,1 NDC

RxNorm SCD

RxNorm SBD

0,1

0,1

1,1 NDC

RxNorm SCD

RxNorm SBD

0,1 HL79068

0,1




LOINC code


Value

90411-6 NARCOTIC (OPIOID) AGONIST, USE FOR TREATMENT

OF OPIOID ADDICTION - OPIOID DISCONTINUED

This conveys whether the addicted drug has been discontinued.

N No

Y Yes


OF OPIOID ADDICTION - DATE OPIOID DISCONTINUED

Date that the object drug of the addiction was discontinued or is planned to be discontinued


OF OPIOID ADDICTION - INDUCTION THERAPY DATE

INITIATED

Date induction therapy initiated or to be initiated.

90414-6 NARCOTIC (OPIOID) AGONIST USE FOR TREATMENT

OF OPIOID ADDICTION, INDUCTION THERAPY – DATE

ORAL INITIATED

Date to switch to oral medication if induction therapy initiated with injectable drug.

90415-6 NARCOTIC (OPIOID) AGONIST USE FOR TREATMENT

OF OPIOID ADDICTION - DURATION

Planned length of time on agonist treatment.


OF OPIOID ADDICTION - DOSE TITRATION

Description of the titration plan or the agonist including time line.

Data

Type

CE

DT

DT

DT

NM

TX

CDAR1AIS0010R010


/ Numeric Units

1,1 HL70136

1,1

1,1

0,1

1,1 iso+

1,1

3.7 Imidazole - Related Antifungals Value Table

Table 3.7 Imidazole - Related Antifungals Value Table

LOINC code


Value

90010-x PRESCRIBER INFORMATION





This may be repeated to convey multiple identifications such as the National Provider Identifier [NPI], the Drug Enforcement

Act [DEA] number, Special DEA number, HCIdea number or proprietary identifier.




CODE

Taxonomy code that identifies the medical specialty of the prescriber



Data

Type

PN

CX

CE

Card

1,1

Response

Code

/ Numeric Units

1,1

1,n NPI

DEA

HCIdea

Proprietary

Provider ID

See note at left.

1,1 PTX

Page 37

November

2005


LOINC code


Value

90020-x

90030-x




NUMBER




DRUG PRESCRIBED







Data

Type

TX

TX

TX

CE

CDAR1AIS0010R010

Card

0,1

Response

Code

/ Numeric Units

1,1

0,1

1,1

1,1

1,1 NDC

RxNorm SCD

RxNorm SBD

Page 38

November

2005




LOINC code


Value Data

Type

90420-7









N No

Y Yes

DRUG PRESCRIBED, TOPICAL THERAPY

Information about why a topical therapy was prescribed.

90421-7 DRUG PRESCRIBED, TOPICAL THERAPY - REASON

The reason a topical therapy was prescribed.

UTS Unable to swallow

HDS Hepatic Dysfunction

OTH Other (If used, then Topical Therapy Reason – Other must be completed)

90422-7 DRUG PRESCRIBED , TOPICAL THERAPY- REASON,

OTHER

Description of reason for topical therapy, required when response to Drug Prescribed, Topical Therapy - Reason equals

90430-7

"OTH" Other.

IMIDAZOLE-RELATED ANTIFUNGALS, RELATED

DIAGNOSIS


90431-7 IMIDAZOLE-RELATED ANTIFUNGALS, RELATED

DIAGNOSIS



US.

90432-7 IMIDAZOLE-RELATED ANTIFUNGALS, DIAGNOSIS

CONFIRMED BY

This conveys the diagnostic procedures used to establish the diagnosis.


90433-7 IMIDAZOLE-RELATED ANTIFUNGALS, DIAGNOSIS

CONFIRMED BY - OTHER

Name/description of other test used to confirm the diagnosis.

Required when the answer to Patient History, Diagnosis

Confirmed equals "OTH" Other.

CE

CE

TX

CE

CE

CE

TX

CDAR1AIS0010R010

Card Response

Code

/ Numeric Units

1,1 HL79038

0,1 HL70136

0,1

1,1 HL79069

0,1

1,1

1,1 IC9

IC10

0,n HL79070

0,1



Page 39

November

2005


LOINC code


Value Data

Type

CDAR1AIS0010R010

Card

1,1

Response

Code

/ Numeric Units

90440-7

90450-7

FUNGAL INFECTION INFORMATION

Information about the fungal infection.

90441-7 FUNGAL INFECTION INFORMATION, LOCATION

This defines the general site of the fungal infection.

FN Finger Nail

TN Toe Nail

OTH Other (If used, then Fungal Infection Information,

Location – Other must be completed)

90442-7 FUNGAL INFECTION INFORMATION, LOCATION –

OTHER

Description of the location of the fungal infection. Required when Fungal Infection Information, Location equals "OTH"

Other

90443-7 FUNGAL INFECTION INFORMATION, NUMBER OF

NAILS

Enumerates the number of affected finger and or toe nails.

IMMUNE COMPROMISE INFORMATION

Information regarding the source and verification of the patient’s immune compromise.

90451-7 IMMUNE COMPROMISE INFORMATION, CAUSE

This conveys the cause of the patient's immune compromise.

DIS Disease

TRP Transplant

MED Medical Intervention

NA Not Applicable

90452-7 IMMUNE COMPROMISE INFORMATION, VERIFIED BY

This identifies the laboratory procedure used to verify immune compromise.

CD4 CD4 Count

ANC ANC Count

WBC White Blood Cell Count

90460-7 CO-MORBID CONDITON INFORMATION

Information regarding the presence of other conditions as factor in the existence and treatment of the fungal infection.

90461-7 CO-MORBID CONDITON INFORMATION, LIVER

DYSFUNCTION INDICATOR

This provides information regarding the presence of liver dysfunction as factor in the continuation and treatment of the fungal infection..

N No

Y Yes


DYSFUNCTION - CONFIRMED BY

This defines the tests used to verify the liver dysfunction.


CE

TX

NM

CE

CE

CE

Page 40

November

2005

1,n HL79071

0,1

0,1 iso+

0,n

1,n HL79072

0,n HL79073

0,1

0,1 HL70136

1,1 HL79074




LOINC code


Value Data

Type


DYSFUNCTION COMFIRMED BY – OTHER

Description of test used to confirm Liver Dysfunction. Required when the response to Co-morbid Condition Information, Liver

Dysfunction - Confirmed By equals "OTH" Other.

90464-7 COMORBID CONDITON INFORMATION, MEDICARE

90070-x

ESRD CERTIFICATION - INDICATOR

This provides information regarding the presence of End Stage

Renal Disease as factor in the continuation and treatment of the fungal infection, based on Medicare ESRD certification.

Y Yes

N No

MEDICARE ESRD CERTIFICATION DATE

90470-7

90480-7

90070-x .

Date patient was certified by Medicare as having End Stage

Renal Disease

LEVEL OF FUNCTIONAL IMPAIRMENT

This conveys functional limitations resulting from or

90470-7

See section 5 for the list of valid codes. exacerbating the fungal infection .

INPATIENT TREATMENT INFORMATION

Required if the patient is being discharged from an inpatient hospital stay during which anti-fungal treatment was

90080-x administered.

90481-7 INPATIENT TREATMENT INFORMATION, IV ANTI-

FUNGAL THERAPY INDICATOR

Indicator to define whether IV Anti-fungal therapy was provided during the admission.

N No

Y Yes

90482-7 INPATIENT TREATMENT INFORMATION, IV ANTI-

FUNGAL THERAPY – AGENT(S)

Name of the IV Therapy Agents given during the hospital stay.




DRUG NAME



DRUG CODE


TX

CE

DT

CE

CE

TX

TX

CE

CDAR1AIS0010R010

Card

0,1

Response

Code

/ Numeric Units

1,1 H70136

0,1

1,1

0,1

1,n HL79075

0,1

1,1 HL70136

0,1

0,n

1,1

1,1 NDC

RxNorm SCD

RxNorm SBD



Page 41

November

2005


LOINC code


Value

90490-7


DURATION OF THERAPY



REASON(S) PRIOR THERAPY DISCONTINUED

This is the reason that the prior drug therapy was discontinued.




OTH Other


REASON PRIOR THERAPY DISCONTINUED – OTHER






The descriptive name of the drug(s) incompatible with the prior therapy. If Drug History, Prior Therapy for Diagnosis - Reason


IMIDAZOLE-RELATED ANTIFUNGALS, PRIOR

THERAPY TYPE

The route of the previously used medication for treatment of the fungal infection.

90490-7 IMIDAZOLE-RELATED ANTIFUNGALS, PRIOR

THERAPY TYPE

Type of drug therapy previously used for treatment of the fungal infection.

90090-x

ORL Oral

TOP Topical

INJ Injectible

IV Intravenous




This is the descriptive name of the drugs) the patient is currently on, for this or other diagnoses, which might impact the requested drug.




Data

Type

NM

CE

TX

TX

CE

TX

CE

CDAR1AIS0010R010

Card Response

Code

/ Numeric Units

1,1 iso+

1,1 HL79040

0,1

0,n

0,1 HL79076

0,n

0,1

1,1 NDC

RxNorm SCD

RxNorm SBD

Page 42

November

2005




4 Coding Examples

CDAR1AIS0010R010

4.1 Scenario

Sara J. Smith is a 50 year old female receiving care for hepatic dysfunction and a persistent fungal infection of her right foot. She returned to her physician, Robert J Podell, MD, a Hepatologist

(Taxonomy 207RI0008X) for a follow-up evaluation on 12/28/2005. Ms. Smith’s medical record number is 184569

The findings at this time revealed that the medication, Tinactin Cream, had not proved effective in controlling the Tenea Pedis infection. Because of her diminished liver function Ms. Smith is unable to take a systemic anti-fungal medication, so Dr. Podell decides to order Oxistat Cream, 1%, 60 gram tube (NDC-0173-0423-04) as a replacement therapy.

Ms. Smith has medical and drug coverage through Aetna Insurance, Plan ID 10567432.Her Aetna patient ID is 352584768003G. The Plan’s drug benefit is administered by ReadiRx PBM. On checking the Plan formulary, Dr. Podell finds that Oxistat Cream is a covered benefit requiring prior authorization. Using the Plan’s Antifungal PA Attachment and criteria for coverage of coverage of Oxistat Cream, he reviews Ms. Smith’s medical record to assure that she meets the criteria and to collect the information needed for the request. Dr. Podell’s Aetna provider ID is

4376557IM.

The following information was collected from the medical record. The diagnosis requiring the use of the ordered drug is 110.4 - Tinea Pedis. This diagnosis was confirmed by KOH Preparation performed on 9/15/2004. The use of a topical drug is required because of Liver Dysfucntion as confirmed by a 7/15/2004 Hepatic Function Panel. The fungal infection is located between the toes of her right foot and at this point is not causing or impacted by any function limitations. The previous treatment which proved ineffective, was with Tinactin Cream, NDC-0085-0715-07.

The request associated with this CDA document is identified by the value XA728302 as it’s attachment control number. This is used for linking purposes within the 278 and 275.

Figure 4.1 Drug Prior Authorization Additional Data

PRESCRIBER NAME Podell MD, Robert J

PRESCRIBER IDENTIFIER 4376557IM

PRESCRIBER TAXONOMY 207RI0008X

PRESCRIBER CONTACT PHONE # 765-228-1234

PRESCRIBER CONTACT FAX # 765-228-3123

DRUG PRESCRIBED, NAME (TEXT) Oxistat, Cream, 1%, 60-g tube

DRUG PRESCRIBED, DRUG CODE 0173-0423-04

DRUG PRESCRIBED, THERAPY TYPE Replacement (RPLRQ)

DRUG PRESCRIBED, REASON FOR Hepatic Dysfunction (HDS)

TOPICAL THERAPY

RELATED DIAGNOSIS (TEXT) Tinea Pedia

RELATED DIAGNOSIS (CODE) 110.4

RELATED DIAGNOSIS CONFIRMED BY KOH Preparation (KOH)

INFECTION LOCATION Between toes, right foot (OTH)

LIVER DYSFUNCTION INDICATOR Yes (Y)

LIVER DYSFUNTION CONFIRMED BY Hepatic Function Panel (HFP)



Page 43

November

2005


MEDICARE ESRD CERTIFICATION Yes (Y)

INDICATOR

PRIOR THERAPY, DRUG NAME Tinactin, Cream

PRIOR THERAPY, DRUG CODE 0085-0715-07

PRIOR THERAPY, DURATION 90 days

PRIOR THERAPY, RREASON PRIOR Not or no longer effective (NTEFF)

THERAPY DISCONTINUED

PRIOR THERAPY, TYPE Topical (TOP)

CDAR1AIS0010R010

4.1.1 Drug Prior Authorization Attachment, Human-Decision Variant (XML body)

The right column of the example below contains the single HL7 document in the human-decision variant that conveys this report in its entirety. The left column provides help in relating the example to the scenario and to the Value Table.

Example 4.1.1 Drug Prior Authorization Attachment, Human-Decision Variant (XML body)

Header

Provider

Identification

Patient

Identification

Attachment Control

Number

< 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 levelone_1.0.attachments.xsd

">

< clinical_document_header >

< id EX =" a123 " RT =" 2.16.840.1.113883.3.933

"/>

< document_type_cd V =" 99999-7 " DN =" Imidazole

–Related Antifungals Attachment

"/>

< origination_dttm V =" 2006-01-05 "/>

< provider >

< provider.type_cd

V =" PRF "/>

< person >

< id EX =" 4376557IM " RT =" 2.16.840.1.113883.19.10.1

"/>

< person_name >

< nm >

< v3dt:GIV V =" Robert "/>

< v3dt:MID V =" J "/>

< v3dt:FAM V =" Podell "/>

< v3dt:SFX V =" MD "/>

</ nm >

< person_name.type_cd

V =" L " S =" 2.16.840.1.113883.12.200

"/>

</ person_name >

</ person >

</ provider >

< patient >

< patient.type_cd

V =" PATSBJ "/>

< person >

< id EX =" 352584768003G " RT =" 2.16.840.1.113883.19.10.2

"/>

< person_name >

< nm >

< v3dt:GIV V =" Sara "/>

< v3dt:MID V =" J "/>

< v3dt:FAM V =" Smith "/>

</ nm >


V =" L " S =" 2.16.840.1.113883.12.200

"/>

</ person_name >

</ person >

< is_known_by >

< id EX =" 184569 " RT =" 2.16.840.1.1138863.19.10.3

"/>

< is_known_to >

< id EX =" 352584768003G " RT =" 2.16.840.1.113883.19.10.2

"/>

</ is_known_to >

</ is_known_by >

</ patient >

< local_header descriptor =" Att_ACN ">

< local_attr name =" attachment_control_number " value =" XA728302 "/>

</ local_header >

</ clinical_document_header >

Page 44

November

2005




Prescriber

Information (Name,

Identifier and

Taxonomy)

Prescriber Contact

Information (phone and fax numbers)

Drug Prescribed

Information (Name of Drug, Drug Code and Therapy Type)

Drug Prescribed,

Reason for Topical

Therapy

Related Diagnosis

Information

(Diagnosis

Description and

Code and how the diagnosis was confirmed)

Fungal Infection

Location

CDAR1AIS0010R010

< body >

< section >

< caption > PRESCRIBER INFORMATION </ caption >

< paragraph >

< caption > PRESCRIBER INFORMATION, NAME </ caption >

< content > Robert J. Podell, MD </ content >

</ paragraph >

< paragraph >

< caption > PRESCRIBER INFORMATION, IDENTIFIER </ caption >

< content > 4376557IM </ content >

</ paragraph >

< paragraph >

< caption > PRESCRIBER INFORMATION, SPECIALTY

TAXONOMY </ caption >

< content > Hepatologist (207RI0008X) </ content >

</ paragraph >

</ section >

< section >

< caption > PRESCRIBER CONTACT INFORMATION </ caption >

< paragraph >

< caption > PRESCRIBER CONTACT INFORMATION, PHONE

NUMBER </ caption >

< content > (765) 228-1234 </ content >

</ paragraph >

< paragraph >

< caption > PRESCRIBER CONTACT INFORMATION, FAX

NUMBER </ caption >

< content > (765) 228-3123 </ content >

</ paragraph >

</ section >

< section >

< caption > DRUG PRESCRIBED </ caption >

< paragraph >

< caption > DRUG PRESCRIBED, NAME </ caption >

< content > Oxistat Cream, 1%, 60g tube </ content >

</ paragraph >

< paragraph >

< caption > DRUG PRESCRIBED, DRUG CODE </ caption >

< content > 0173-0423-04 (NDC) </ content >

</ paragraph >

< paragraph >

< caption > DRUG PRESCRIBED, THERAPY TYPE </ caption >

< content > Replacement (RPLRQ) </ content >

</ paragraph >

</ section >

< section >

< caption > DRUG PRESCRIBED, REASON FOR TOPICAL THERAPY </ caption >

< paragraph >

< content > Hepatic Dysfunction (HDS) </ content >

</ paragraph >

</ section >

< section >

< caption > IMIDAZOLE-RELATED ANTIFUNGALS, RELATED

DIAGNOSIS </ caption >

< paragraph >

< caption > IMIDAZOLE-RELATED ANTIFUNGALS, RELATED

DIAGNOSIS </ caption >

< content > Tinea Pedia (ICD-9-CM 110.4) </ content >

</ paragraph >

< paragraph >

< caption > IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS -

CONFIRMED BY </ caption >

< content > KOH Preparation (KOH) </ content >

</ paragraph >

</ section >

< section >

< caption > FUNGAL INFECTION LOCATION </ caption >

< paragraph >

< content > Between Toes, right foot (OTH) </ content >

</ paragraph >



Page 45

November

2005


Liver Dysfunction

Information

(Indicator and how it was confirmed)

Medicare ESRD

Certification

Indicator

Drug History, Prior

Therapy for

Diagnosis (Prior

Therapy Drug

Name, Code,

Duration, and

Reason for

Discontinuance)

Prior Therapy Type

CDAR1AIS0010R010

</ section >

< section >

< caption > CO-MORBID CONDITION INFORMATION </ caption >

< paragraph >

< caption > CO-MORBID CONDITION INFORMATION, LIVER DYSFUNCTION

INDICATOR </ caption >

< content > yes (Y) </ content >

</ paragraph >

< paragraph >

< caption > CO-MORBID CONDITION INFORMATION, LIVER DYSFUNCTION

CONFIRMED BY </ caption >

< content > Hepatic Function Panel (HFP) </ content >

</ paragraph >

</ section >

< section >

< caption > MEDICARE ESRD CERTIFICATION INDICATOR </ caption >

< paragraph >

< content > Yes (Y) </ content >

</ paragraph >

</ section >

< section >

< caption > DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS </ caption >

< paragraph >

< caption > DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG

NAME </ caption >

< content > Tinactin Cream </ content >

</ paragraph >

< paragraph >


CODE </ caption >

< content > 0085-0715-07 (NDC) </ content >

</ paragraph >

< paragraph >

< caption > DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS -

DURATION OF THERAPY </ caption >

< content > 90 days </ content >

</ paragraph >

< paragraph >

< caption > DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON

PRIOR THERAPY DISCONTINUED </ caption >

< content > Not or no longer effective (NTEFF) </ content >

</ paragraph >

</ section >

< section >

< caption > IMIDAZOLE-RELATED ANTIFUNGALS, PRIOR THERAPY

TYPE </ caption >

< paragraph >

< content > Topical (TOP) </ content >

</ paragraph >

</ section >

</ body >

</ levelone >

Figure 1 shows the human-decision variant (XML body) as rendered by a popular browser.

Figure 1. Rendered Human-Decision Variant (XML body)

Drug Prior Authorization Attachment

Provider: Robert J Podell,

Page 46

November

2005




MD

Patient: Sara J Smith Provider's Pt ID: 352584768003G

Attachment Control Number: XA728302

CDAR1AIS0010R010


PRESCRIBER INFORMATION, NAME. Robert J. Podell, MD

PRESCRIBER INFORMATION, IDENTIFIER. 4376557IM

PRESCRIBER INFORMATION, SPECIALTY TAXONOMY. Hepatologist

(207RI0008X)


PRESCRIBER CONTACT INFORMATION, PHONE NUMBER. (765) 228-1234

PRESCRIBER CONTACT INFORMATION, FAX NUMBER. (765) 228-3123

DRUG PRESCRIBED

DRUG PRESCRIBED, NAME. Oxistat Cream, 1%, 60g tube

DRUG PRESCRIBED, DRUG CODE. 0173-0423-04 (NDC)

DRUG PRESCRIBED, THERAPY TYPE. Replacement (RPLRQ)

DRUG PRESCRIBED, REASON FOR TOPICAL THERAPY

Hepatic Dysfunction (HDS)

IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS

IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS. Tinea Pedia

(ICD-9-CM 110.4)

IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS - CONFIRMED

BY. KOH Preparation (KOH)

FUNGAL INFECTION LOCATION

Between Toes, right foot (OTH)

CO-MORBID CONDITION INFORMATION

CO-MORBID CONDITION INFORMATION, LIVER DYSFUNCTION INDICATOR. yes (Y)

CO-MORBID CONDITION INFORMATION, LIVER DYSFUNCTION

CONFIRMED BY. Hepatic Function Panel (HFP)



Page 47

November

2005


MEDICARE ESRD CERTIFICATION INDICATOR

Yes (Y)


CDAR1AIS0010R010

DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG NAME. Tinactin

Cream

DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG CODE. 0085-0715-

07 (NDC)

DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DURATION OF

THERAPY. 90 days

DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR

THERAPY DISCONTINUED. Not or no longer effective (NTEFF)

IMIDAZOLE-RELATION ANTIFUNGALS, PRIOR THERAPY TYPE

Topical (TOP)

Page 48

November

2005




4.1.2 Drug Prior Authorization Attachment, Human-Decision Variant (non-XML body)

The right column of the example below contains the single HL7 Additional Information CDA document in the human-decision variant that conveys this report in its entirety. The left column provides help in relating the example to the scenario and to the Value Table.

Example 4.1.2 Drug Prior Authorization Attachment, Human-Decision Variant (non-XML body)

Header

Provider

Identification

Patient

Identification

Attachment Control

Number

MIME Reference for Antifungal

Report

Base64 Encoded

Antifungal Report

(this is an example of a portion of the

MIME packaging)


">


< id EX =" a123 " RT =" 2.16.840.1.113883.3.933

"/>

< document_type_cd V =" 99999-7 " DN =" Imidazole –Related Antifungals Attachment "/>


< provider >

< provider.type_cd

V =" PRF "/>

< person >

< id EX =" 4376557IM " RT =" 2.16.840.1.113883.19.10.1

"/>

< person_name >

< nm >


< v3dt:MID V =" J "/>



</ nm >


V =" L " S =" 2.16.840.1.113883.12.200

"/>

</ person_name >

</ person >

</ provider >

< patient >

< patient.type_cd

V =" PATSBJ "/>

< person >

< id EX =" 352584768003G " RT =" 2.16.840.1.113883.19.10.2

"/>

< person_name >

< nm >


< v3dt:MID V =" J "/>


</ nm >


V =" L " S =" 2.16.840.1.113883.12.200

"/>

</ person_name >

</ person >

< is_known_by >

< id EX =" 184569 " RT =" 2.16.840.1.1138863.19.10.3

"/>

< is_known_to >

< id EX =" 352584768003G " RT =" 2.16.840.1.113883.19.10.2

"/>

</ is_known_to >

</ is_known_by >

</ patient >



</ local_header >


< body >

< non_xml MT =” image/tif ”>

< v3dt:REF V = ” Antifungal report.tif

”/>

</ non_xml >

</ body >

</ levelone >

--192.168.0.132.1.111780.1044168570.525.24086

Content-Type: image/tif

Content-Transfer-Encoding: base64

Content-Disposition: attachment; filename=Antifungal report.tif



Page 49

November

2005


R0lGODlhAAJ9AfAAAP///wAAACwAAAAAAAJ9AUAC/wQShrqcb06SrNITm57bTvqB0dWRUM al nmqubkuib0lDyHIrYz2zPPzDZUbEou5oJNpiuVPDIXngptIqkIP5aFesq2eIDGLDPhksiU47 nsVbiOqeotjtnPp+f8a17FAFTrez95Yid6FkZ4e24cdocSiIJzlJWWl5WekWNVjot9kUZ8YZ tfmpF/q5VmWFmRl4xBkrO6topNmKm6u7y9vr+/u7J+k5WVure5wJlhTafKuICrwGBkhrfS2c

(Editor’s note: 149 lines have been suppressed for readability.)

SmW6Sr0UTL2M5ut4yN5k7soG7vici6fc6QHbTh+khPZMrOHMrvfaCpkaUNm0rvTUBcSEJ6cQ o+wwjU0oJrAQ74fqZ+jewudY7N5KEOPm6rVEcMoOqbVaD/1ubkQyba+eiRj0TwZ/LteWkAmt

Yf8QcMwmRGuCkAajRZjSYm+ojQq30FL6zu24EAzrJ8XCkAzl4fTKEA3TUA3XkA3b0A3fEA7j

0C0IAAUAOw==

--192.168.0.132.1.111780.1044168570.525.24086

Figure 2 shows the human-decision variant (non-XML body) as rendered by a popular browser.

Figure 2. Rendered Human-Decision Variant (non-XML body)

Imidazol-Related Antifungals Attachment

Provider:

Robert J Podell,

MD



Click here to view report.

Page 50

November

2005






Page 51

November

2005


4.1.3 Coded Drug Prior Authorization Attachment, Computer-Decision Variant

The right column of the example below contains the single HL7 Additional Information CDA document in the computer-decision variant that conveys this report in its entirety. The left column provides help in relating the example to the scenario and to the Value Table.

Page 52

November

2005

Example 4.1.2 Drug Prior Authorization Attachment, Computer-Decision Variant

Header

Provider

Identification

Patient

Identification

Attachment Control

Number

Prescriber

Information (Name,

Identifier and

Taxonomy)


">


< id EX =" a123 " RT =" 2.16.840.1.113883.3.933

"/>

< document_type_cd V =" 99999-7 " DN =" Imidazole –Related Antifungals Attachment "/>


< provider >

< provider.type_cd

V =" PRF "/>

< person >

< id EX =" 4376557IM " RT =" 2.16.840.1.113883.19.10.1

"/>

< person_name >

< nm >


< v3dt:MID V =" J "/>



</ nm >


V =" L " S =" 2.16.840.1.113883.12.200

"/>

</ person_name >

</ person >

</ provider >

< patient >

< patient.type_cd

V =" PATSBJ "/>

< person >

< id EX =" 352584768003G " RT =" 2.16.840.1.113883.19.10.2

"/>

< person_name >

< nm >


< v3dt:MID V =" J "/>


</ nm >


V =" L " S =" 2.16.840.1.113883.12.200

"/>

</ person_name >

</ person >

< is_known_by >

< id EX =" 184569 " RT =" 2.16.840.1.1138863.19.10.3

"/>

< is_known_to >

< id EX =" 352584768003G " RT =" 2.16.840.1.113883.19.10.2

"/>

</ is_known_to >

</ is_known_by >

</ patient >



</ local_header >


< body >

< section >

< caption > PRESCRIBER INFORMATION

< caption_cd V =" 90010=x " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>

</ caption >

< paragraph >

< caption > PRESCRIBER INFORMATION, NAME

< caption_cd V =" 90011-x " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>

</ caption >

< content > Robert J. Podell, MD

< local_markup descriptor =" dt_PN ">

< local_markup descriptor =" dt_PN_GIV " ignore =" all "> ROBERT </ local_markup >

< local_markup descriptor =" dt_PN_MID " ignore =" all "> J </ local_markup >




Prescriber Contact

Information (phone and fax numbers)

Drug Prescribed

Information (Name of Drug, Drug Code and Therapy Type)

CDAR1AIS0010R010

< local_markup descriptor =" dt_PN_FAM " ignore =" all "> PODELL </ local_markup >

< local_markup descriptor =" dt_PN_SFX " ignore =" all "> MD </ local_markup >

</ local_markup >

</ content >

</ paragraph >

< paragraph >

< caption > PRESCRIBER INFORMATION, IDENTIFIER

< caption_cd V =" 90012-x " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>

</ caption >

< content > 4376557IM

< local_markup descriptor =" dt_CX ">

< local_attr name =" dt_CX_EX " value =" 4376557IM "/>

< local_attr name =" dt_CX_RT " value =" 2.16.840.1.113883.19.10.1

"/>

</ local_markup >

</ content >

</ paragraph >

< paragraph >

< caption > PRESCRIBER INFORMATION, SPECIALTY TAXONOMY

< caption_cd V =" 90013-x " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>

</ caption >

< content > 207RI0008X Hepatologist

< coded_entry >

< coded_entry.value

V =" 207RI0008X " S =" 2.16.840.1.113883.6.101

"

SN =" USProvTxnmy "/>

</ coded_entry >

</ content >

</ paragraph >

</ section >

< section >

< caption > PRESCRIBER CONTACT INFORMATION

< caption_cd V =" 90020-x " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>

</ caption >

< paragraph >

< caption > PRESCRIBER CONTACT INFORMATION, PHONE NUMBER

< caption_cd V =" 90021-x " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>

</ caption >

< content > (765)228-1234 </ content >

</ paragraph >

< paragraph >

< caption > PRESCRIBER CONTACT INFORMATION, FAX NUMBER

< caption_cd V =" 90022-x " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>

</ caption >

< content > (765)228-3123 </ content >

</ paragraph >

</ section >

< section >

< caption > DRUG PRESCRIBED

< caption_cd V =" 90030-x " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>

</ caption >

< paragraph >

< caption > DRUG PRESCRIBED, NAME

< caption_cd V =" 90031-x s=2.16.840.1.113883.6.1

" SN =" loinc "/>

</ caption >

< content > Oxistat Cream, 1%, 60g tube </ content >

</ paragraph >

< paragraph >

< caption > DRUG PRESCRIBED, DRUG CODE

< caption_cd V =" 90032-x " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>

</ caption >

< content > 0173-0423-04 Oxistat Cream, 1%, 60g tube

< coded_entry >

< coded_entry.value

V =" 0173-0423-04 " S =" 2.16.840.1.113883.5.141

"

SN =" NDC "/>

</ coded_entry >

</ content >

</ paragraph >

< paragraph >

< caption > DRUG PRESCRIBED, THERAPY TYPE

< caption_cd V =" 90033-x " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>



Page 53

November

2005


Drug Prescribed,

Reason for Topical

Therapy

Related Diagnosis

Information

(Diagnosis

Description and

Code and how the diagnosis was confirmed)

Fungal Infection

Location

Co-Morbid

Condition

Information (Liver

Dysfunction)

(Indicator and how it was confirmed)

CDAR1AIS0010R010

</ caption >

< content > Replacement (RPLRQ)

< coded_entry >

< coded_entry.value

V =" RPLRQ " S =" 2.16.840.1.113883.12.9038

"

SN =" HL79038 "/>

</ coded_entry >

</ content >

</ paragraph >

</ section >

< section >

< caption > DRUG PRESCRIBED, REASON FOR TOPICAL THERAPY

< caption_cd V =" 90420-7 " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>

</ caption >

< paragraph >

< content > Hepatic Dynsfunction (HDS)

< coded_entry >

< coded_entry.value

V =" HDS " S =" 2.16.840.1.113883.12.9069

"

SN =" HL79069 "/>

</ coded_entry >

</ content >

</ paragraph >

</ section >

< section >

< caption > IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS

< caption_cd V =" 90430-7 " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>

</ caption >

< paragraph >

< caption > IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS

< caption_cd V =" 90431-7 " S =" 2.16.840.1.113883.6.1

"

SN =" LOINC "/>

</ caption >

< content > Tinea Pedia 110.4 (ICD-9-CM)

< coded_entry >

< coded_entry.value

V =" 110.4

" S =" 2.16.840.1.113883.12.6.2

"

SN =" ICD-9-CM "/>

</ coded_entry >

</ content >

</ paragraph >

< paragraph >

< caption > IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS -

CONFIRMED BY < caption_cd V =" 90432-7 "

S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>

</ caption >

< content > KOH Preparation (KOH)

< coded_entry >

< coded_entry.value

V =" KOH " S =" 2.16.840.1.113883.12.9070

"

SN =" HL79070 "/>

</ coded_entry >

</ content >

</ paragraph >

</ section >

< section >

< caption > FUNGAL INFECTION LOCATION - OTHER

< caption_cd V =" 90442-7 " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>

</ caption >

< paragraph >

< content > Between toes, right foot </ content >

</ paragraph >

</ section >

< section >

< caption > CO-MORBID INFORMATION

< caption_cd V =" 90460-7 " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>

</ caption >

< paragraph >

< caption > CO-MORBID INFORMATION, LIVER DYSFUNCTION INDICATOR

< caption_cd V =" 90461-7 " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>

</ caption >

< content > Yes (Y)

< coded_entry >

Page 54

November

2005




Medicare ESRD

Certification

Indicator

Drug History, Prior

Therapy for

Diagnosis (Prior

Therapy Drug

Name, Code,

Duration, and

Reason for

Discontinuance)

CDAR1AIS0010R010

< coded_entry.value

V =" Y " S =" 2.16.840.1.113883.12.136

"

SN =" HL70136 "/>

</ coded_entry >

</ content >

</ paragraph >

< paragraph >

< caption > CO-MORBID INFORMATION, LIVER DYSFUNCTION

CONFIRMED BY

< caption_cd V =" 90462-7 " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>

</ caption >

< content > Hepatic Function Panel (HFP)

< coded_entry >

< coded_entry.value

V =" HFP " S =" 2.16.840.1.113883.12.9074

"

SN =" HL79074 "/>

</ coded_entry >

</ content >

</ paragraph >

</ section >

< section >

< caption > MEDICARE ESRD CERTIFICATION INDICATOR

< caption_cd V =" 90070-x " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>

</ caption >

< paragraph >

< content > Yes (Y)

< coded_entry >

< coded_entry.value

V =" Y " S =" 2.16.840.1.113883.12.136

"

SN =" HL70136 "/>

</ coded_entry >

</ content >

</ paragraph >

</ section >

< section >

< caption > DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS

< caption_cd V =" 90080-x " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>

</ caption >

< paragraph >


NAME

< caption_cd V =" 90081-x " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>

</ caption >

< content > Tinactin Cream </ content >

</ paragraph >

< paragraph >


CODE

< caption_cd V =" 90082-x " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>

</ caption >

< content > 0085-0715-07 (NDC)

< coded_entry >

< coded_entry.value

V =" 0085-0715-07 "

S =" 2.16.840.1.113883.5.141

" SN =" NDC "/>

</ coded_entry >

</ content >

</ paragraph >

< paragraph >

< caption > DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS -

DURATION OF THERAPY

< caption_cd V =" 90083-x " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>

</ caption >

< content > 90 days

< local_markup descriptor =" dt_nm " ignore =" all "> 90

< coded_entry >

< coded_entry.value

V =" days " S =" 2.16.840.1.113883.6.2

"/>

</ coded_entry >

</ local_markup >

</ content >

</ paragraph >

< paragraph >


PRIOR THERAPY DISCONTINUED

< caption_cd V =" 90084-x " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>



Page 55

November

2005


Prior Therapy Type

CDAR1AIS0010R010

</ caption >

< content > Not or no longer effective (NTEFF)

< coded_entry >

< coded_entry.value

V =" NTEFF " S =" 2.16.840.1.113883.12.9040

"

SN =" HL79040 "/>

</ coded_entry >

</ content >

</ paragraph >

</ section >

< section >


PRIOR THERAPY DISCONTINUED

< caption_cd V =" 90084-x " S =" 2.16.840.1.113883.6.1

" SN =" LOINC "/>

</ caption >

< paragraph >

< content > Topical (TOP)

< coded_entry >

< coded_entry.value

V =" TOP " S =" 2.16.840.1.113883.12.9076

"

SN =" HL79076 "/>

</ coded_entry >

</ content >

</ paragraph >

</ section >

</ body >

</ levelone >

Figure 3 shows a portion of the computer-decision variant as rendered by a popular browser. It includes the medications rendered as a table.

Figure 3. Rendered Human-Decision Variant (non-XML body)

Imidazol-Related Antifungals Attachment

Provider:

Robert J Podell,

MD




PRESCRIBER INFORMATION, NAME. Robert J. Podell, MD

PRESCRIBER INFORMATION, IDENTIFIER. 4376557IM

PRESCRIBER INFORMATION, SPECIALTY TAXONOMY. 207RI0008X

Hepatologist


PRESCRIBER CONTACT INFORMATION, PHONE NUMBER. (765)228-1234

PRESCRIBER CONTACT INFORMATION, FAX NUMBER. (765)228-3123

DRUG PRESCRIBED

DRUG PRESCRIBED, NAME. Oxistat Cream, 1%, 60g tube

Page 56

November

2005




DRUG PRESCRIBED, DRUG CODE. 0173-0423-04 Oxistat Cream, 1%, 60g tube

DRUG PRESCRIBED, THERAPY TYPE. Replacement (RPLRQ)

DRUG PRESCRIBED, REASON FOR TOPICAL THERAPY

Hepatic Dynsfunction (HDS)

IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS

IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS. Tinea Pedia

110.4 (ICD-9-CM)

IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS - CONFIRMED

BY. KOH Preparation (KOH)

FUNGAL INFECTION LOCATION - OTHER

Between toes, right foot

CO-MORBID INFORMATION

CO-MORBID INFORMATION, LIVER DYSFUNCTION INDICATOR. Yes (Y)

CO-MORBID INFORMATION, LIVER DYSFUNCTION CONFIRMED BY. Hepatic

Function Panel (HFP)

MEDICARE ESRD CERTIFICATION INDICATOR

Yes (Y)


DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG NAME. Tinactin

Cream

DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG CODE. 0085-0715-

07 (NDC)

DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DURATION OF

THERAPY. 90 days

DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR

THERAPY DISCONTINUED. Not or no longer effective (NTEFF)

DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR THERAPY DISCONTINUED

Topical (TOP)



Page 57

November

2005


5 Response Code Sets

This section describes response codes that may be used in the computer-decision variant when the value table indicates a coded with exception (CE) data type or to represent units when the attachment component is of the numeric (NM) data type. The entry in the value table that refers to these code sets is used in the subsection titles.

The values for some code sets appear directly in this document. In other cases, the section cites another document as the source.

5.1 HL70136: Yes-No Indicator

The OID for this table is 2.16.840.1.113883.12.136.

Table 5.1 Yes-No Indicator

N

Code Description

No

Y Yes

Additional Comments

5.2 HL79038: Drug Prescribed, Therapy Type


Table 5.2 Drug Prescribed, Therapy Type





ADDRQ Add-on Therapy


5.3 HL79039: UTC, Diagnosis Confirmed By


Table 5.3 UTC, Diagnosis Confirmed By


LABT Laboratory Examination

RADT

OTDX

Radiological Examination

Other Diagnostic Examination

CLNE Clinical Evaluation


Page 58

November

2005




5.4 HL79040: Reason Prior Therapy Discontinued


Table 5.4 Reason Prior Therapy Discontinued





OTH Other

CDAR1AIS0010R010


Not compatible with other required drugs.

If used, then Reason Prior

Therapy Discontinued – Other must be completed

5.5 HL79041: NSAIDS/PPI Related Concurrent Therapy, Type


Table 5.5 NSAIDS – COX 2 Inhibitors, Concurrent Therapy - Type


CRTC Corticosteroid

ANCG

ANPL

PPI

Anti-coagulant

Anti-platelet

Proton Pump Inhibitor

H2RA

NSAD

BPHN

ANNP

H2 Receptor Antagonist

NSAIDS

Biphosphonate

Anti-neoplastic

FAP

ASAL

ASAG

OTH

For Familial Adenomatous Polposis

ASA<325mg/day

ASA>325mg/day

Other


If used, then Drug History,

Other Drug Type must be completed.

5.6 HL79042: NSAID Use, Duration


Table 5.6 NSAID Use, Duration


G21 NSAID Use greater than 21 days

L21 NSAID Use less than 21 days

5.7 HL79043: Yes-No-Unknown Indicator


Table 5.7 HL7 NSAID Use, Duration

Y


Yes

N

U

No

Unknown





Page 59

November

2005


5.8 HL79044: Radiology Diagnosis Confirmation, Study Type

CDAR1AIS0010R010


Table 5.8 Radiology Diagnosis Confirmation, Study Type


BAE Bone Age

BDY

MRI

Bone Density

Magnetic Resonance Imaging (MRI)

ESX X-Ray to Determine Epiphyseal Status


5.9 HL79045: Laboratory Diagnosis Confirmation, Study/Test


Table 5.9 Laboratory Diagnosis Confirmation, Study/Test


IGB3 IGFBP3

IGF1

ITT

IGF1

Insulin Tolerance

ACTH

TSH

LIP

GHA

ACTH

TSH

Lipid Level

Combined GHRH and Arginine

GTP

FTST

GT

OTH

Gonadotropin

Free Testosterone

Genetic Testing

Other


If ITT contraindicated.

If used, then Laboratory

Diagnosis Confirmation

Information, Other Study/Test

Name must be used.

5.10 HL79046: GH, Patient History

– Documented Onset


Table 5.10 GH, Patient History – Documented Onset


AO Adult Onset

CO Childhood Onset

UO Unknown Onset


5.11 HL79047: GH, Patient History Information – Hypothalmic Pituitary Disease

Induced By


Table 5.11 GH, Patient History Information – Hypothalmic Pituitary Disease Induced

By

Page 60

November

2005





PTT Pituitary Tumor

IRR Irradiation

SUG

HMN

TRA

Surgery

Hormone Dysfunction or Therapy

Trauma

CDAR1AIS0010R010


5.12 HL79048: Treatment Status


Table 5.12 Treatment Status


AT In Progress/Active Treatment

IT

CP

PT

NT

PL

Initial Course of Treatment

Completed

Previously Treated

New Course of Treatment

Planned


5.13 HL79049: GHD Childhood Information, Puberty Status


Table 5.13 GHD Childhood Information, Puberty Status


BP Pre-pubertal

AP

PS

Post Pubertal

Pubertal


5.14 HL79050: GH Dysfunction Adult Information, Secondary Causes


Table 5.14 GH Dysfunction Adult Information, Secondary Causes

A


Age

O

D

O

Obesity

Depression

Other


If used, then Secondary Causes

Other must be completed.

5.15 HL79051: Nutritional Information, Assessment Indicator


Table 5.15 Nutritional Information, Assessment Indicator


CMP Completed

PLD Planned


5.16 HL79052: Parental Height, Availability Indicator




Page 61

November

2005


Table 5.16 Parental Height, Availability Indicator


MK Mother Known

FK

BK

BU

Father Known

Both Known

Both Unknown

CDAR1AIS0010R010


5.17 HL79053: Diagnosis Confirmation and Level of Treatment Needed,

Procedure Employed


Table 5.17 Diagnosis Confirmation and Level Treatment Needed, Procedure Employed


BMS Barium Studies

EGD

BIO

Endoscopy

Biopsy


5.18 HL79054: Diagnosis Confirmation and Level of Treatment Needed, GERD

By Endoscopy Type


Table 5.18 Diagnosis Confirmation and Level of Treatment Needed, GERD By

Endoscopy Type


ERSV1 Erosive Grade 1




NERSV Non Erosive


5.19 HL79055: H-Pylori Information, Status


Table 5.19 H-Pylori Information, Status


PS Positive

NE Negative

5.20 HL79056: H-Pylori Information, Confirmed By


Table 5.20 H-Pylori Information, Confirmed By


Page 62

November

2005





SROL Serology

URBT Urease Breath Test

FSGS

B1HA

SCST

OTH

Feasting Serum Gastrin

Basal 1 Hour Acid Output

Secretion Simulation Test

Other

CDAR1AIS0010R010


If used, then H-Pylori

Information Confirmed by

Other is required.

5.21 HL79057: ED, Related Diagnosis Confirmation, Confirmed By


Table 5.21 ED, Related Diagnosis Confirmation, Confirmed By


TST Tertosterone Level

PRL

THY

NA

OTH

Prolactin Level

Thyroid Level

Not Applicable

Other Test


If used, then ED, Related

Diagnosis Confirmation,

Confirmed By Other is required.

5.22 HL79058: ED, Patient History – Pulmonary Hypertension Functional Level


Table 5.22 ED, Patient History – Pulmonary Hypertension Functional Level


C1 Class I

C2 Class II

C3

C4

Class III

Class IV


5.23 HL79059: ED, Patient History – Evaluation Type


Table 5.23 ED, Patient History – Evaluation Type


GH General Health Status Evaluation

UC Investigation of Underlying Causes of Primary

NA

Condition

Not Applicable


5.24 HL79060: ED, Patient History – ED Related To


Table 5.24 ED, Patient History – ED Related To



Page 63

November

2005



END Endocrine Disorder

URS Urogenital Surgery

SPC

TSC

PSG

Spinal Cord Injury

Testicular Cancer

Psychogenic

CDAR1AIS0010R010


5.25 HL79061: ED, Treatment of Related Causes – Psychogenic Causes of ED

Treatment


Table 5.25 ED, Treatment of Related Causes – Psychogenic Causes of ED Treatment


PSY Psychotherapy

BHT Behavior Therapy

OTT

NOT

Other Therapy

No Treatment


5.26 HL79062: ED, Treatment of Related Causes

– Drug Induced Option


Table 5.26 ED, Treatment of Related Causes – Drug Induced Option


RDU Reduction in Drug Use

DCT Discontinue Drug Use

CGD

DCN

Change Drug

Drug Cannot be Change or Discontinued


5.27 HL79063: ED Concurrent Therapy, Type


Table 5.27 ED Concurrent Therapy, Type


NTT Nitrate

APB Alpha-Blocker

SRI

PGN

ETA

VDP

OED

SSRI

Prostaglandin for PPH

Endothelium for PAH

Vasodilator for PAH

Other ED Medication


If used, then ED Concurrent

Therapy, Other Type is required.

5.28 HL79064: Narcotic (Opioid) Agonists, Patient History

– Pain Syndrome

Source


Table 5.28 Narcotic (Opioid) Agonists, Patient History – Pain Syndrome Source

Page 64

November

2005





BPN Bone Pain

JPN Joint Pain

MST

VPN

NPN

OTH

Other Somatic Pain (Muscle./Soft Tissue)

Visceral Pain

Neuropathic Pain

Other Pain Syndrome

CDAR1AIS0010R010


If used, then Pain Syndrome

Other is required.

5.29 HL79065: Narcotic (Opioid) Agonists, Patient History – Pain Syndrome

History


Table 5.29 Narcotic (Opioid) Agonists, Patient History – Pain Syndrome History


CP Constant Pain

ITP

ICP

Intermittent Pain

Incidental Pain


5.30 HL79066: Narcotic (Opioid) Agonists, Patient History – Pain Syndrome

Persistence


Table 5.30 Narcotic (Opioid) Agonists, Patient History – Pain Syndrome Persistance


AL Acute Limited – Less Than 30 Days

CR Chronic

CRP

CPR

Chronic Progressive

Chronic Progressive with Escalating Opioid


5.31 HL79067: Narcotic (Opioid) Agonists, Complicating Conditions


Table 5.31 Narcotic (Opioid) Agonists, Complicating Conditions


BRA Bronchial Asthma

PAI Paralytic Ileum

PSY

LDY

KDY

CRP

OTH

Psychiatric Condition

Liver Dysfunction

Kidney Dysfunction

Other Chronic Pulmonary Condition

Other


Diagnosed or suspected.

If used, then Other

Complicating Conditions is required

5.32 HL79068: Opioid Related Concurrent Pain Therapy, Opioid Level


Table 5.32 Opioid Concurrent Pain Therapy, Opioid Level



Page 65

November

2005



RDL Recommended, Dose Level

HPL High Potency Dose Level

24L

OTL

24 Hour High Potency Dose Level

Opioid Tolerant

CDAR1AIS0010R010


5.33 HL79069: Drug Prescribed, Topical Therapy - Reason


Table 5.33 Drug Prescribed, Topical Therapy - Reason


UTS Unable to Swallow

HDS Hepatic Dysfunction

OTH Other


5.34 HL79070: Imidazole – Related Antifungals, Diagnosis Confirmed By


Table 5.34 Imidazole – Related Antifungals, Diagnosis Confirmed By


FCL Fungal Culture

PAS

KOH

PAS Stain Results

KOH Preparation

NBP

OTH

Nail Biopsy

Other


5.35 HL79071: Fungal Infection Information, Location


Table 5.35 Fungal Infection Information, Location


FN Finger Nail

TN Toe Nail

OTH Other


5.36 HL79072: Immune Compromise Information, Cause


Table 5.36 Immune Compromise Information, Cause


DIS Disease

TRP

MED

NA

Transplant

Medical Intervention

Not Applicable


5.37 HL79073: Immune Compromise Information, Verified By


Table 5.37 Immune Compromise Information, Verified By

Page 66

November

2005





CD4 CD4 Count

ANC ANC Count

WBC White Blood Cell Count

CDAR1AIS0010R010


5.38 HL79074: Co-Morbid Condition Information, Liver Dysfunction –

Confirmed By


Table 5.38 Co-Morbid Condition Information, Liver Dysfunction – Confirmed By


HFP Hepatic Function Panel

TAL

TAS

OTH

SGPT, ALT

SGOT, AST

Other


5.39 HL79075: Level of Functional Impairment


Table 5.39 Level of Functional Impairment


AL Ambulation Limitations

CO

DY

EL

Contractures

Dyspnea with Minimum Exertion

Endurance Limitations

PA Painful Ambulation


5.40 HL79076: Imidazole – Related Antifungals, Prior Therapy Type


Table 5.40 Imidazole – Related Antifungals, Prior Therapy Type


ORL Oral

TOP

INJ

Topical

Injectible

IV Intravenous


5.41 I9C : ICD-9-CM

International Classification of Diseases, 9 th Clinical Modification.


5.42 IC10: ICD-10-CM

International Classification of Diseases, 10 th Clinical Modification.

The OID for this table is 2.16.840.1.113883.x.x.



Page 67

November

2005


5.43 iso+: Extended ISO Units Codes

CDAR1AIS0010R010

ISO 2955-1983 and extensions as defined in HL7 Version 2.4 Figure 7-9. Due to its length the table is included in the HL7 Additional Information Specification Implementation Guide rather than in this Additional Information Specification.


5.44 NDC: National Drug Code

The National Drug Code (NDC), administered by the FDA, provides a unique code for each distinct drug, dose form, manufacturer, and package. (Available from the National Drug Code

Director, FDA, Rockville, MD, and other sources.)


5.45 RXNC: RxNorm SCD (Semantic Clinical Drug)

RxNorm, a standardized nomenclature for clinical drugs, is produced by the National Library of

Medicine. In this context, a clinical drug is a pharmaceutical product given to (or taken by) a patient with a therapeutic or diagnostic intent. In RxNorm, the name of a clinical drug combines its ingredients, strengths, and form. RxNorm follows a standard format in the naming of clinical drugs. Drugs named in disparate ways in various other vocabularies are normalized according to

RxNorm’s naming conventions. RxNorm SCD includes ingredient plus strength and dose form.

(Example: Fluoxetine 4 MG/ML Oral Solution).

RxNorm can be obtained from the National Library of Medicine at: www.nlm.nih.gov.

The OID for this table is 2.16.840.1.113883.5.x.xxx.

5.46 RXNB: RxNorm SBD (Semantic Branded Drug)

RxNorm, a standardized nomenclature for clinical drugs, is produced by the National Library of

Medicine. In this context, a clinical drug is a pharmaceutical product given to (or taken by) a patient with a therapeutic or diagnostic intent. In RxNorm, the name of a clinical drug combines its ingredients, strengths, and form. RxNorm follows a standard format in the naming of clinical drugs. Drugs named in disparate ways in various other vocabularies are normalized according to

RxNorm’s naming conventions. RxNorm SBD includes ingredient, strength, and dose form plus brand name. ( Example: Fluoxetine 4 MG/ML Oral Solution [Prozac]).

RxNorm can be obtained from the National Library of Medicine at: www.nlm.nih.gov.

The OID for this table is 2.16.840.1.113883.x.xxx.

5.47 DEA: Drug Enforcement Administration

[Change this description to describe the DEA Number and where to get more information on the

DEA Number. See NDC]

The US Drug Enforcement Administration is charged by statute the maintenance of controls against diversion of controlled substances and with the registration of all manufacturers and distributors of controlled substances and practitioners dispensing schedule III, IV or V drugs. The

DEA number is assigned to practitioners meeting the criteria for dispensing, ordering and management of a patient on narcotic therapy.

Page 68

November

2005




Further information and Application for a DEA number may be obtained at www.dea.gov

Special DEA: Drug Enforcement Administration

The US Drug Enforcement Administration is charged by statute the maintenance of controls against diversion of controlled substances and with the registration of all manufacturers and distributors of controlled substances and practitioners dispensing schedule III, IV or V drugs. The

DEA number is assigned to practitioners meeting the criteria for dispensing, ordering and management of a patient on narcotic therapy. The Drug Addiction Treatment Act of 2000

(DATA2000) allows qualified physicians to practice medication-assisted opioid addiction therapy with specifically FDA-approved Schedule III, IV or V narcotic medications. The practitioner must submit a notice of intent to the Center for Substance Abuse Treatment (CSAT) a component of the Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services. Upon approval the DEA assigns a special identification number in addition to the practitioner’s regular DEA number.

To obtain further information contact www.samhsa.gov

and search waiver qualifications .

Further information and Application for a DEA number may be obtained at www.dea.gov.


5.48 HCI: HCIdea

HCIdea™ is an NCPDP prescriber identity management database solution designed to address the needs of organizations wishing to identify prescribers of drugs. An NCPDP HCIdea™ Prescriber

Identity Layout is available upon request. For information about obtaining the NCPDP HCIdea™ file and the current (version 1.1) file format, please contact Robin Ebert at 480-477-1000, ext. 118 or rebert@HCIdea.org

Contact Information

National Council of Prescription Drug Programs (NCPDP)

9240 East Raintree Drive

Scottsdale, AZ 85260

(480) 477-1000

(480) 767-1042 (fax)


5.49 NPI: National Provider Identifier

On January 23, 2004, the Secretary of HHS published a final rule (Federal Register volume 69, page 3434) which establishes the standard for a unique health identifier for health care providers for use in the health care system, and announces the adoption of the National Provider Identifier

(NPI) as that standard. It also establishes the implementation specifications for obtaining and using the standard unique health identifier for health care providers.

For more information contact the US Department of Health and Human Services, Centers for

Medicare and Medicaid Services (CMS), 7500 Security Blvd., Baltimore, MD 21244

The DHHS Administrative Simplification web site is http://aspe.hhs.gov/admnsimp .



Page 69

November

2005


The OID for this table is 2.16.840.1.113883.4.6

CDAR1AIS0010R010

5.50 PTX: Health Care Provider Taxonomy

The National Uniform Claim Committee (NUCC) maintains the Health Care Provider Taxonomy.

The code set is available through Washington Publishing. See: http://www.wpc-edi.com/codes/


5.51 Miscellaneous OID References

This section contains a list of OID references used in the construct of the CDA header and body not otherwise noted in the above code set and table references.

5.51.1 Unique Instance Identifier

The OID 2.16.840.1.113883.3.933 is used to identify the “unique instance ID” for this document.

5.51.2 person_name.type_cd

OID 2.16.840.1.113883.12.200 is an object identifier for the person_name.type_cd component.

5.51.3 Proprietary Provider ID

OID 2.16.840.1.113883.12.200 is an object identifier for the person_name.type_cd component.

5.51.4 Example OID

In some instances in the example, OID 2.16.840.1.113883.19.7.xxx was used where xxx represents an author assigned number. This is used for demonstration purposes only. The actual OID for that concept will be included in the final published version of the document.

Page 70

November

2005

--End of document--



Drug Prior Authorization Attachment AIS

Additional Information Specification 0010:

Drug Prior Authorization Attachment

Release 1.0

Based on HL7 CDA Standard Release 1.0, with supporting LOINC

Tables

Draft -

December 2006

Table of Contents

Index of Tables and Figures

1 Introduction

2 LOINC Codes

3 Drug Prior Authorization Attachment Value Tables

4 Coding Examples

Drug Prior Authorization Attachment

Imidazol-Related Antifungals Attachment

Imidazol-Related Antifungals Attachment

5 Response Code Sets

Related documents

Products

Support

Drug Prior Authorization Attachment AIS

Additional Information Specification 0010:

Drug Prior Authorization Attachment

Release 1.0

Based on HL7 CDA Standard Release 1.0, with supporting LOINC

Tables

Draft -

December 2006

Table of Contents

Index of Tables and Figures

1 Introduction

2 LOINC Codes

3 Drug Prior Authorization Attachment Value Tables

4 Coding Examples

Drug Prior Authorization Attachment

Imidazol-Related Antifungals Attachment

Imidazol-Related Antifungals Attachment

5 Response Code Sets

Related documents

Add this document to collection(s)

Add this document to saved

Suggest us how to improve StudyLib