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 | Newborn's Delivery Information | Newborn hearing screen reason not performed of ear - left | The reason why the hearing screen was not done in left ear. |
73739-5 - Newborn hearing screen reason not performed of Ear - left (including Preferred Answer List LL2769-9) |
Craig Newman | Altarum | ||
| Level 0 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter subject | 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 | Care Team Members | Information about a person who participates or is expected to participate in the care of a patient. |
Provider DEA Number | NPPES assigns a unique number to each registered provider DEA assigns a number to each requesting and qualified healthcare professional. |
Robert C Dieterle | On behalf of the Da Vinci Project | ||
| Level 0 | Care Team Members | Information about a person who participates or is expected to participate in the care of a patient. |
Provider NPI | NPPES assigns a unique number to each registered provider DEA assigns a number to each requesting and qualified healthcare professional. |
Robert C Dieterle | On behalf of the Da Vinci Project | ||
| Level 0 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter status | 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. |
Location Associated Time Period | Encounter type/occurrence: SNOMED CT (example, value set OID: 2.16.840.1.113883.3.666.5.307) HCPCS (example, value set OID: 2.16.840.1.113883.3.464.1003.101.12.1087) CPT (example, value set OID: 2.16.840.1.113883.3.464.1003.101.12.1001) HL7 value set, encounter type: https://www.hl7.org/fhir/us/core/ValueSet-us-core-encounter-type.html Encounter Diagnosis/ Primary Diagnosis/Discharge Diagnosis: SNOMED CT ICD-10-CM Discharge Disposition: DischargeDisposition Code System http://terminology.hl7.org/CodeSystem/discharge-disposition Encounter Location: SNOMED HSLOC |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| Level 0 | Newborn's Delivery Information | Newborn hearing screen reason not performed of ear - right | The reason why the hearing screen was not done in right ear. |
73742-9 - Newborn hearing screen reason not performed of Ear - right (including Example Answer List LL2769-9) |
Craig Newman | Altarum | ||
| Level 0 | Newborn's Delivery Information | Newborn hearing screen of ear - left | The hearing screening result for the leftear provides coded result values for pass, refer and not performed. There should be separate results for both the right Ear and left ear. |
54108-6 - Newborn hearing screen of Ear - left (including Preferred Answer List LL618-0) |
Craig Newman | Altarum | ||
| Level 0 | Newborn's Delivery Information | Newborn hearing screen of ear - right | The hearing screening result for the right ear provides coded result values for pass, refer and not performed. There should be separate results for both the right Ear and left ear. |
54109-4 - Newborn hearing screen of Ear - right (including Preferred Answer List LL618-0) |
Craig Newman | Altarum | ||
| Level 0 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Imaging Study - Content | Representation of the content produced in a DICOM imaging study. A study comprises a set of series, each of which includes a set of Service-Object Pair Instances (SOP Instances - images or other data) acquired or produced in a common context. A series is of only one modality (e.g. X-ray, CT, MR, ultrasound), but a study may have multiple series of different modalities. |
DICOM |
Deanne Kasim | Change Healthcare | |
| Level 0 | Newborn's Delivery Information | Gestational Age at Birth | LOINC codes are available for gestational age |
Kensaku Kawamoto, MD, PhD, MHS | University of Utah | |||
| Level 0 | Cancer Care | Surgical Procedure As Part of Treatment | Was a of surgery used as part of treatment for this diagnosis (e.g., Yes, No, Indeterminant)? |
American Joint Committee on Cancer e.g. AJCC8 |
Charles Mayo, PhD | University of Michigan | ||
| Level 0 | Cancer Care | Systemic Therapy As Part of Treatment | Was a of systemic therapy used as part of treatment for this diagnosis? |
American Joint Committee on Cancer e.g. AJCC8 |
Charles Mayo, PhD | University of Michigan | ||
| Level 0 | Cancer Care | Structure Type | Defines if the radiation therapy structure a target structure (e.g. PTV, CTV, GTV) or an organ at risk. Standard Values (List): Target; Organ at Risk |
Elizabeth Covington | University of Michigan | |||
| Level 0 | Cancer Care | Radiation Therapy Dose Objective | TG-263 (https://www.aapm.org/pubs/reports/RPT_263.pdf) name of DVH metric for the objective |
Elizabeth Covington | University of Michigan | |||
| 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. |
Diagnosis Code Type | Indicates if the diagnosis is admitting, principal, other, an external cause of injury or secondary |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Cancer Care | Radiation Therapy Structure Name | TG-263 (https://www.aapm.org/pubs/reports/RPT_263.pdf) name of structure, if it exists. |
Elizabeth Covington | University of Michigan | |||
| 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. |
Service to Date | Date on which services ended. Located on CMS 1500 (Form Locator 24A) |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Cancer Care | Radiation Therapy Prescription Number of Sessions Per Day | Used to capture BID, TID and other approaches intentionally treating more than one radiation therapy session per day to enhance biological effect. |
Elizabeth Covington | University of Michigan | |||
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administered Performer | Indicates who or what performed the medication administration and how they were involved. |
Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org |
Maria Michaels | CDC |