Condition, diagnosis, or reason for seeking medical attention.

Data Element
Problems, defined by ICD-10-CM terminology standards
Description

Information about condition, diagnosis, or other event, situation, issue, or clinical concept that is documented.
Submitted By: Joel Andress / Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
Data Element Information
Data Element Description Information about condition, diagnosis, or other event, situation, issue, or clinical concept that is documented.
Rationale for Separate Consideration The current concept of problems/diagnoses is included in USCDI v1. This submission is to recommend expansion of the applicable standards to include both SNOMED and ICD-10-CM.
Use Case Description(s)
Use Case Description Diagnosis/condition information defined by ICD-10 terminology is used extensively in CMS quality measures across programs including IQR, QPP, PAC, and Promoting Interoperability to define measurement populations. This concept is widely defined by SNOMED and ICD-10-CM terminology. ICD-10 is mandated for CMS billing and is reviewed and audited for those purposes, and therefore is an accurate source of condition information and a preferred source of condition data for many use cases.
Estimate the breadth of applicability of the use case(s) for this data element More than 4,000 hospitals and 1 million providers currently capture, access and exchange diagnosis data using ICD-10 terminology. ICD-10 is mandated for CMS billing, and therefore used by all stakeholders interfacing with Medicare and Medicaid beneficiaries.
In addition to CMS mandate, On January 16, 2009, the U.S. Department of Health and Human Services (HHS) released the final rule mandating that everyone covered by the Health Insurance Portability and Accountability Act (HIPAA) implement ICD-10 for medical coding.
eCQI resource center, includes measure specifications for CMS program eCQMs: https://ecqi.healthit.gov/ecqms
CMS and HHS regulation: https://www.cms.gov/Medicare/Coding/ICD10/Statute_Regulations

Link to use case project page https://ecqi.healthit.gov/ecqms
Use Case Description Problems/diagnoses defined by ICD-10 codes are also used extensively for clinical care, care decision support, and exchanged for patients across the continuum of care.

ICD-10 terminology is an accepted and frequently used terminology for this type of clinical exchange of data using C-CDA.
Estimate the breadth of applicability of the use case(s) for this data element ICD-10 for medical coding is required for everyone covered by HIPPA, and also required for CMS billing, and therefore is widely used/captured by all stakeholders. ICD-10 data is also electronically exchanged with patients and payers.
http://www.hl7.org/implement/standards/product_brief.cfm?product_id=492
https://bluebutton.cms.gov/
Link to use case project page http://www.hl7.org/implement/standards/product_brief.cfm?product_id=492
Use Case Description This use case was submitted by Holly Miller, MD, MedAllies.

Either pushed or queried interoperable messages from one provider or organization to the next caregiver for the patient will include both ICD and SNOMED codes for problems/diagnoses to support semantic interoperability across systems and prevent errors that might occur from different systems disparate mapping methodologies.
Current State

Provider in system A documents a patient's problem/diagnoses using ICD 10 codes and links each element in the plan of care to the specific diagnosis that it is related to. In the background, system A maps the ICD 10 code to a SNOMED code using their preferred mapping processes.
Provider in system B who is next taking care of the patient is either pushed or queries for an interoperable message that includes the SNOMED problem/diagnosis codes. In the background, system B maps each problem/diagnosis SNOMED code to the corresponding ICD 10 codes using system B’s mapping methodology resulting in some differences among the original and reconciled ICD 10 codes received from system A.
Future State

Provider in system A documents a patient's problems/diagnoses using ICD 10 codes and links each element in the plan of care to the specific diagnosis that it is related to. In the background, system A maps the ICD 10 codes to the corresponding SNOMED codes using their preferred mapping processes.
Provider in system B who is next taking care of the patient is either pushed or queries for an interoperable message that includes both the original ICD 10 codes documented in system A as well as the SNOMED problem/diagnosis codes that were mapped by system A. The correct ICD 10 codes are reconciled and the linked treatment plan elements to each code can be retained. The received SNOMED codes are also stored by system B.
Estimate the breadth of applicability of the use case(s) for this data element Estimate the number of stakeholders who would capture, access, use or exchange this data element or data class: Level 2
All providers in the United States that document their patients' problems/diagnoses using ICD CM codes in their EHRs (the vast majority).
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
  • Improving the health of populations
  • Reducing the cost of care
  • Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) ICD-10
https://icd.who.int/browse10/2019/en
https://vsac.nlm.nih.gov/welcome
http://hl7.org/fhir/us/core/STU3.1/ValueSet-us-core-condition-code.html

https://icd.who.int/browse10/2019/en
Additional Specifications Many technical specification use/allow use of ICD-10 terminology to define diagnoses including:
HL7 FHIR US Core Implementation Guide STU3 based on FHIR R4, Condition Profile, specifically can use ICD-10 terminology for encounter diagnoses (https://www.hl7.org/fhir/us/core/StructureDefinition-us-core-condition.html )
HL7 FHIR QI Core Implementation Guide STU4 based on FHIR R4, Condition Profile http://hl7.org/fhir/us/qicore/StructureDefinition-qicore-condition.html
CMS Quality Data Model (QDM) version 5.5 Guidance (https://ecqi.healthit.gov/sites/default/files/QDM-v5.5-Guidance-Update-May-2020-508.pdf)
HL7 C-CDA Release 2.0 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=492)
Current Use This data element has been used at scale between multiple different production environments to support the majority of anticipated stakeholders
Supporting Artifacts ICD-10 terminology is mandated for CMS billing, and therefore used by all stakeholders interfacing with Medicare and Medicaid beneficiaries; ICD-10 for medical coding is also required for everyone covered by HIPPA and therefore used at scale between multiple different production environments.
It is also widely available in EHR systems.
https://fhir.cerner.com/millennium/r4/general-clinical/condition/#terminology-bindings
https://fhir.epic.com/Specifications?api=949
https://open.epic.com/Interface/FHIR
https://mydata.athenahealth.com/fhirapidoc
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Quality-Programs
https://ecqi.healthit.gov/ecqms

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Quality-Programs
Extent of exchange 5 or more. This data element has been tested at scale between multiple different production environments to support the majority of anticipated stakeholders.
Supporting Artifacts ICD-10 terminology to define diagnoses is electronically exchanged for quality measurement used across CMS programs—it is exchanged electronically from EHR systems via QRDA files as well as in claims.
ICD-10 codes are also routinely electronically exchanges with external organizations via C-CDA to support the continuum of care and with patients via CMS.
https://ecqi.healthit.gov/qrda
http://www.hl7.org/implement/standards/product_brief.cfm?product_id=7

https://ecqi.healthit.gov/qrda
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) No challenges anticipated. This terminology has been in use for many years and is widely used.
Restrictions on Use (e.g. licensing, user fees) None
Privacy and Security Concerns This data, like any patient data, should be exchanged securely. Current processes exist, governed by CMS and ONC, to securely transfer this data.
Estimate of Overall Burden No burden estimated—terminology in use across the entire stakeholder community.
Other Implementation Challenges N/A

Comment

Log in or register to post comments

FormGuide

Help

1. Optional: Background Text / Cover Letter

The "Optional Background Text / Cover Letter" field provides space for additional context or introductory information related to your comment.

If you wish to provide context, explanation, or an introduction to your comment, enter this information in the field labeled "Optional Background Text / Cover Letter." This is entirely optional and is most useful when submitting multiple related comments or when additional background would help reviewers understand your feedback.

If you are only commenting on a single data class or element, you may leave this field blank.

2. Select the Data Class

To specify which data class your comment addresses:

  1. In the "Data Class" drop-down menu, select the appropriate data class you want to comment on.
  2. If you are providing a general comment that is not specific to a data element, select "General" from the options. Comments with this designation will be displayed on the USCDI landing page.
  3. Note that the Data Class field will automatically populate based on your current location in the platform:
    1. If you are on a data class page, the field will be set to that specific data class
    2. If you are on a data element page, the corresponding data class will be pre-selected
       

3. Select the Data Element

To specify which data element your comment addresses:

  1. In the "Data Element" drop-down menu, select the specific data element you want to comment on.
  2. The drop-down menu will display only the elements available under the data class you selected in the previous step.
  3. You can use the search function within the drop-down to quickly locate a specific data element.
  4. If you are commenting on the data class itself rather than a specific element, you may leave this field blank.

Note: Comments on a specific data element will appear on the respective data element page, while comments on a data class (without a specific element selected) will appear on the landing page for that data class.
 

Data Class and Data Element

Fig 1 The "Data Class" and "Data Element" dropdown menus allow users to specify the exact content they wish to comment on.

4. Optional: Propose New Data Class or Element

If you cannot find the appropriate data class or element for your comment:

  1. Instead of clicking the "Comment On An Existing Data Class Or Element" button, click the adjacent button labeled "Propose a New Data Class or Data Element."
  2. This will redirect you to the ONDEC (ONC New Data Element and Class) Submission System.
  3. In the ONDEC system, follow the provided instructions to submit your proposal for a new data class or element.
  4. Once your proposal is submitted through ONDEC, it will be reviewed separately from the commenting process.
Propose New Data Class or Element

Fig 2 The "Propose a New Data Class or Data Element" button redirects users to the ONDEC Submission System for proposing new data elements not currently available in the system.

5. Complete the Comment Form

Fill out the required fields in the comment form:

Subject: Enter a brief, descriptive title that summarizes your comment. This helps reviewers quickly understand the nature of your feedback.

Comment: In this field, provide the full details of your comment or feedback. Be as clear and specific as possible about your suggestions, concerns, or observations. Include any relevant details that support your position.

6. Optional: Add Additional Comments

If you need to comment on multiple data classes or elements:

  1. After completing your first comment, click the link labeled "Comment on another data element" at the bottom of the form.
  2. A new comment section will appear, allowing you to enter details for your additional comment.
  3. For each additional comment, you must select the appropriate data class and data element from the drop-down menus.
  4. Complete the Subject and Comment fields for your additional comment.
  5. Repeat this process for each additional comment you wish to submit.

Fig 3 The "Comment on another data element" link enables users to create multiple comments addressing different elements within a single submission.

7. Optional: Upload Supporting Files

The platform allows you to upload supporting documentation to enhance your comment:

  • Locate the "File Upload" section at the bottom of the comment form.
  • Click to upload any files (such as PDFs or documents) that provide additional context, evidence, or clarification for your comment.

Important: If you have already entered your comments using the form fields, there is no need to upload duplicate content in PDF format. The file upload feature is intended for supplementary materials only. Please avoid uploading files that contain the same information already provided in your comment text.

Upload Supporting Files

Fig 4 The "File Upload" section permits users to attach supporting documentation that supplements their written comments.

8. Optional: Save and Exit

If you need to pause your work and return to complete your comment later:

  1. Click the "Save and Exit" button at the bottom of the form.
  2. Your comment will be saved as a draft that you can access and complete later.
  3. When you return to the platform, you will see a red triangle with an exclamation mark next to the “Return to saved Comment” button, indicating that you have saved comments in draft status.
  4. Click this button to continue working on your draft.
  5. You will be taken to a review page where you can:
    1. Select "Submit Comment" to officially submit your feedback.
    2. Click "Edit" to return to the comment form and make changes
    3. Select "Discard Draft" to delete the saved draft and start fresh

Fig 5 A red triangle with exclamation mark indicator appears next to the “Return to saved Comment” button when draft comments are saved in the system.

9. Review and Submit

Once you have completed your comment:

  1. Click the "Review and Submit" button at the bottom of the form.
  2. This will take you to a review screen displaying your comment(s) in full.
  3. Review all information for accuracy and completeness.
  4. On this review screen, you have three options: 
    1. Click "Submit Comment" to officially submit your feedback
    2. Click "Edit" to return to the comment form and make changes
    3. Click "Discard Draft" to delete the comment and start fresh
  5. The review screen also includes a "Print" button that allows you to create a printed copy of your comments for your records. 
  6. If you choose to submit, your comment will be recorded in the system and made available for review by the appropriate stakeholders.
Review and Submit

Fig 6 The review screen allows users to verify comment content and make any necessary modifications before final submission.

USCDI Comments

Close

Add a New Comment

Review comment and Submit

Edit
Comment #1