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. |
Refill Number | The number fill of the current dispensed supply (0, 1, 2, etc.). |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Participant | Encounter Status: FHIR Encounter Status: http://hl7.org/fhir/ValueSet/encounter-status Classification of Encounter: V3 Value SetActEncounterCode: http://hl7.org/fhir/ValueSet/v3-ActEncounterCode Encounter Type: FHIR Encounter type: http://www.ama-assn.org/go/cpt Encounter participant type: FHIR Participant type: http://hl7.org/fhir/ValueSet/encounter-participant-type Reason for the encounter: FHIR Encounter Reason Codes: http://hl7.org/fhir/ValueSet/encounter-reason Hospital encounter discharge disposition: FHIR Discharge disposition: http://hl7.org/fhir/ValueSet/encounter-discharge-disposition Expected source(s) of payment for this encounter: FHIR Coverage Type and Self-Pay Codes: http://hl7.org/fhir/R4/valueset-coverage-type.html Encounter chief complaint: FHIR DiagnosisRole: http://hl7.org/fhir/R4/valueset-diagnosis-role.html |
Maria Michaels | CDC | ||
| Level 0 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Participant Time Period | Encounter Status: FHIR Encounter Status: http://hl7.org/fhir/ValueSet/encounter-status Classification of Encounter: V3 Value SetActEncounterCode: http://hl7.org/fhir/ValueSet/v3-ActEncounterCode Encounter Type: FHIR Encounter type: http://www.ama-assn.org/go/cpt Encounter participant type: FHIR Participant type: http://hl7.org/fhir/ValueSet/encounter-participant-type Reason for the encounter: FHIR Encounter Reason Codes: http://hl7.org/fhir/ValueSet/encounter-reason Hospital encounter discharge disposition: FHIR Discharge disposition: http://hl7.org/fhir/ValueSet/encounter-discharge-disposition Expected source(s) of payment for this encounter: FHIR Coverage Type and Self-Pay Codes: http://hl7.org/fhir/R4/valueset-coverage-type.html Encounter chief complaint: FHIR DiagnosisRole: http://hl7.org/fhir/R4/valueset-diagnosis-role.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. |
Prescription Origin Code | Whether the prescription was transmitted as an electronic prescription, by phone, by fax, or as a written paper copy |
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. |
Plan Reported Brand-Generic Code | Whether the plan adjudicated the claim as a brand or generic drug. |
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 Identifier Type | Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber. |
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 Billing Provider NPI | The National Provider Identifier assigned to the Billing Provider. |
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 | |
| Level 0 | Observations | Findings or other clinical data collected about a patient during care. |
Observation Code | The concept identifying what was tested, measured, or observed. Data Type: CodeableConcept Permissible Values: The observation identifier SHALL be from LOINC if the concept is present in LOINC. |
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 | |
| Level 0 | Observations | Findings or other clinical data collected about a patient during care. |
Observation Timing | The time or time-period the observed value is asserted as being true. For biological subjects (e.g. human patients) this is typically called the "physiologically relevant time", which is usually either the time of the procedure or of specimen collection. Very often the source of the date/time information is not known, only the date/time itself. Data Type: variable. Allowable data types include: dateTime, Period, Timing, instant Note: An observation time is essential for understanding the context and clinical meaning of an observation. For nationwide interoperability, systems must support the ability to representing this time, even if it is not present for all observations. |
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 | |
| 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 Site of Service Network Status | Indicates the network status of the site of service. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Substance Use | Ethanol in blood | This data element includes the mass/volume of ethanol present in blood |
Most of the requested data elements are in LOINC, as per the codes below. We have requested the addition of the NIAAA Single-Item Screener and the diagnosis of Alcohol Use Disorder to LOINC. AUDIT-C : 72109-2 Ethanol in blood: 5640-8 Ever drink alcohol: 69721-9 Average daily alcohol intake: 74013-4 Alcohol binge episodes/month: 11286-2 Alcohol abuse or dependence: 74043-1 Alcohol help during pregnancy: 64718-0 |
Laura Kwako | National Institute on Alcohol Abuse and Alcoholism | ||
| Level 0 | Allergies and Intolerances | Harmful or undesired physiological responses associated with exposure to a substance. |
Food Allergy Intolerance | Common food substances and allergens that can cause harmful or undesirable physioloical responses when exposed to the substance or the substance is consumed. |
SNOMED CT with a value set created in VSAC (OID: 2.16.840.1.113762.1.4.1186.3) HL7 Cross Paradigm Specification: Allergy and Intolerance Substance Value Set(s) Definition: http://www.hl7.org/implement/standards/product_brief.cfm?product_id=482 was used to create the value set |
Becky Gradl | Academy of Nutrition and Dietetics | |
| 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 Received Date | The date the claim was received by the payer. |
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 Referring Physician NPI | The NPI of the referring physician. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Discharge medications | Indication that a medication should be taken by or given to the patient after being discharged from an encounter. |
Medications (including medications with dose): RxNORM Medication Route: SNOMED (i.e. OID: 2.16.840.1.113883.3.117.1.7.1.222) Negation Rationale (reason codes): SNOMED (i.e. OID: 2.16.840.1.113883.3.117.1.7.1.93) https://vsac.nlm.nih.gov/valueset/expansions?pr=ecqm Negation Rationale: https://www.hl7.org/fhir/valueset-reason-medication-not-given-codes.html , http://hl7.org/fhir/us/qicore/ValueSet-qicore-negation-reason.html |
Joel Andress | CMS | |
| Level 0 | Observations | Findings or other clinical data collected about a patient during care. |
Observation Performer | Who was responsible for asserting the observed value as "true". Many observations will be asserted by a clinician in the care of a patient, but this data element also explicitly allows record of patients, caregivers, and other entities as the source. Such information is crucial for understanding context for observations derived from patient reported outcomes measures. Data Type: Reference (Practitioner, PractitionerRole, Organization, CareTeam, Patient, RelatedPerson). This data element may be a pointer into a record in another table/structure that contains more metadata about the performer. In other contexts, it may be a data type that carries all of the requisite identifying information "inline", such as the XCN (Extended Composite ID Number and Name for Persons) data type used in HL7 v2 OBX-16. |
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 | |
| 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 Billing Provider Contracting Status | Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission. |
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. |
DAW Product Selection Code | Prescriber's instruction regarding substitution of generic equivalents or order to dispense the specific prescribed medication. |
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 Attending Physician NPI | The National Provider Identifier assigned to the Attending Physician for the admission |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners |