USCDI Export for the Public
| Classification Level Sort descending | Data Class | Data Class Description | Data Element | Data Element Description | Applicable Standards | Submitter Name | Submitter Organization | Submission Date |
|---|---|---|---|---|---|---|---|---|
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Claim Non-covered Amount | The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Immunizations | Record of vaccine administration. |
Texas IIS Consent Date | This variable contains the date consent was obtained or changed. When a provider queries ImmTrac for a patient and a patient who has already consented is found, the query will return the Texas IIS Consent Date stored in the registry. The provider, at the patient’s (or parent/guardian’s direction, as appropriate) can change the consent status. If there is a change, the updated Texas IIS Consent Date should be submitted to the IIS. Texas IIS Consent Date should be stored in date format: YYYYMMDD. |
Texas Immunization Registry - ImmTrac | |||
| Level 0 | Immunizations | Record of vaccine administration. |
Texas IIS Consent Status | This element will document the patient’s consent for participating in the Texas statewide immunization information system (IIS). Under state statute, the Texas immunization registry is opt-in.. The following are the different values Texas currently uses to desctibe a patient’s consent status: TXA - Consented Adult, >=18 years old TXY - Consented ImmTrac Child, <18 years of age TXR - First Responder, >=18 years old TXF - Adult Family Member of a First Responder, >=18 years old TXM - Minor Family Member of a First Responder, <18 years old - no consent is on file. After the first initial consent is sent to the registry, the EHR vendor would need to be able to leave the field blank when the patient's information is sent again to the registry. |
Texas Immunization Registry - ImmTrac | |||
| Level 0 | Immunizations | Record of vaccine administration. |
Texas Disaster Consent | The following value should be used to document patient consent during a disaster or pandemic in Texas: TXD – Disaster consent In Texas, there is legislation that requires health care providers to report antiviral, immunization or other medications (AIM) administered to patients in response to a disaster such as COVID-19. When the AIM information is reported the TX IIS (ImmTrac) flags the information as disaster-related. If the patient signs the disaster-related consent form, their personal and disaster related AIMs are stored for the patient’s lifetime. If the patient does not sign the disaster related consent form or the regular, applicable consent form but receives a disaster related AIM, then their personal information and disaster related AIMs are stored in Texas’ IIS for up to 5 years after the end of the disaster. It is crucial for Electronic Health Records to capture, store, and exchange information regarding whether the patient received an AIM that was administered in response a disaster/pandemic so that this information can be shared with others to ensure appropriate medications are delivered and patient health can be maximized.. |
Texas Immunization Registry - ImmTrac | |||
| Level 0 | Immunizations | Record of vaccine administration. |
Reason Immunization Not Performed | Indicates the reason the immunization event was not performed. |
Immunization Code: CVX: Vaccines Administered 2.16.840.1.113762.1.4.1010.6: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1010.6/expansion Immunization Code: National Drug Codes (NDC): http://www2a.cdc.gov/vaccines/iis/iisstandards/ndc_tableaccess.asp Immunization Status: FHIR Immunization Status Codes: http://hl7.org/fhir/ValueSet/immunization-status Immunization Administered Date: FHIR datatypes: dateTime, String: https://www.hl7.org/fhir/us/core/StructureDefinition-us-core-immunization-definitions.html#Immunization.occurrence[x] Reason Immunization Not Performed: FHIR Immunization Status Reason Codes: http://hl7.org/fhir/R4/valueset-immunization-status-reason.html |
Maria Michaels | CDC | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Claim Payment Amount | The amount sent to the payee from the health plan. This amount is to exclude any member cost sharing. It should include the total of member and provider payments. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Member Reimbursement | The amount paid to the member. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Immunizations | Record of vaccine administration. |
Vaccination Administration Date | The date the vaccination event occurred. |
LOINC:30952-6- Date and time of vaccination: https://loinc.org/30952-6/ |
Nedra Garrett | Centers for Disease Control and Prevention | |
| Level 0 | Travel Information | Travel Plans Dates | Dates planned for travel to a location. |
Geographical location history (https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.3201) ISO 3166 country codes (https://www.iso.org/iso-3166-country-codes.html) |
Craig Newman | Altarum | ||
| Level 0 | Travel Information | Travel Plans Location | Represents a location in a person’s travel plans (either an address or a coded location). |
§ SNOMED: 420008001 |Travel (event)| § Geographical location history (https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.do 11.3201) § ISO 3166 country codes (https://www.iso.org/iso-3166-country-codes.html) § NCI_Thesaurus 22.08e: code C173619 § LOINC v2.72 code: PhenX measure - international travel history:-:Pt:^Patient:-:PhenX (Code 62887-5) |
Craig Newman | Altarum | ||
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Claim Amount Paid to Provider | The amount paid to the provider. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Pregnancy Information | Gestational Age | "The estimated gestational age (in weeks, or weeks and fraction of week) of the pregnancy at the time of the health care encounter (in contrast to the gestational age at birth), beginning from the time of fertilization. Needs to be correlated with the date the gestational age was documented. Gestational age (written with both weeks and days) is calculated using the best obstetrical estimated delivery date (EDD) based on the following formula: Gestational Age = (280 - (EDD - Reference Date))/ 7" |
https://www.hl7.org/implement/standards/product_brief.cfm?product_id=494 |
Nedra Garrett | Centers for Disease Control and Prevention | ||
| Level 0 | Health Status Assessments | Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, or patient’s healthcare provider that could identify a need, problem, or condition. |
ECOG | The Eastern Cooperative Oncology Group (ECOG) Performance Status represents the patient's functional status and is used to determine how a disease impacts a patient’s daily living abilities and their overall ability to tolerate therapies in serious illness, specifically for chemotherapy. |
LOINC, SNOMED-CT, and FHIR see: https://search.loinc.org/searchLOINC/search.zul?query=functional+status http://hl7.org/fhir/us/mcode/ https://browser.ihtsdotools.org/?perspective=full&conceptId1=273472005&edition=MAIN/2020-07-31&release=&languages=en |
Andre Quina | MITRE | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Amount Paid by Patient | The amount paid by the member at the point of service. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Claim Total Allowed Amount | The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for non-contracted providers. Allowed amount should not include any COB adjustment. That is, the Allowed amount on a claim should be the same when the Plan is primary or secondary. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Claim Total Submitted Amount | Amount submitted by the provider for reimbursement of health care services. This amount includes non-covered services. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Organization Identifier Type | Identifies the type of identifiers for organizations |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Pregnancy Information | Estimated Date of Delivery | The expected date of delivery (i.e. the due date). |
LOINC codes exist for each of the proposed data elements: 8665-2 - Last menstrual period start date 11778-8 - Delivery date Estimated 56077-1 - Body weight --pre current pregnancy |
Craig Newman | Altarum | ||
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Practitioner Identifier Type | Identifies the type of identifiers for practitioners |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Observations | Findings or other clinical data collected about a patient during care. |
Observation Value | The information determined as a result of making the observation. The information carried by Observation.value may take several forms, depending on the nature of the observation. For example, it could be a quantitative result, and ordinal scale value, nominal or categorial value, etc. Data Type: variable. Possible data types include: Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period Terminology Standards: The appropriate terminology depends on the observation. A few examples: • If the observation is quantitative, then Observation.value.units SHALL be drawn from UCUM. • If the observation represents a validated assessment instrument (e.g. survey) item and the value is a CodeableConcept, then Observation.value.code SHALL be drawn from LOINC. • If the observation pertains to clinical genetics, then other terminologies or syntaxes may be used as appropriate, e.g. HGVS, ClinVar, etc. • If the observation represents a human phenotype, then the Observation.value MAY be drawn from the Human Phenotype Ontology • If the observation has a nominal or ordinal scale value and the Observation.value exists in SNOMED CT, then SNOMED CT MAY be used. |
Vocabulary Standard: No single vocabulary covers the content necessary for representing all aspects of observation reporting (observation identifiers, coded observation values, computable units of measure, etc). Yet, the collection of core vocabularies needed are sufficiently mature. [Observation: Code] LOINC was specifically designed to fulfill the need for a freely available standard for identifying observations. More than 25 years later, it now contains a rich catalog of variables, answer lists, and the collections that contain them. [Observation: Value.units] UCUM was specifically designed to fulfill the need for a freely available standard of computable units of measure. [Observation: Value.code] • If the observation represents a validated assessment instrument (e.g. survey) item and the value is a CodeableConcept, then Observation.value.code SHALL be drawn from LOINC. • If the observation pertains to clinical genetics, then other terminologies or syntaxes may be used as appropriate, e.g. HGVS, ClinVar, etc. • If the observation represents a human phenotype, then the Observation.value MAY be drawn from the Human Phenotype Ontology • If the observation has a nominal or ordinal scale value and the Observation.value exists in SNOMED CT, then SNOMED CT MAY be used Exchange and Analytic CDM specifications: HL7 Version 2: Chapter 7 C-CDA: Results Section (entries required): 2.16.840.1.113883.10.20.22.2.3.1 FHIR: Observation OMOP: Measurement, Observation PCORnet CDM: LAB_RESULT_CM, PRO_CM, OBS_CLIN, OBS_GEN |
Daniel Vreeman | RTI International |