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 Referring Physician Name | The name 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 | Substance Use | Tobacco/Nicotine Product Type | Tobacco/Nicotine containing products used as a method of consumption. Question Prompt: What type(s) of tobacco products? Permissible Values: o Cigarette (SNOMED: 66562002) A thin cylinder of ground or shredded tobacco that is wrapped in paper, lit, and smoked. o Cigar (SNOMED: 26663004) A tube of tobacco that is thicker than a cigarette, wrapped in tobacco leaf, lit, and smoked. Cigars include regular cigars, cigarillos, and little filtered cigars. o Pipe (SNOMED: 84498003) A tube with a small bowl at one end that is filled with tobacco, lit, and smoked. o Smokeless (SNOMED: TBD) This delivery mechanism does not require smoking and includes, Chewing tobacco, Dip, Snuff, Dissolvable and Snus. o E-Cigarette/Vape (SNOMED: TBD) An electronic cigarette is a vaporizer device that simulates smoking by providing some of the aspects of smoking that includes nicotine but without combusting tobacco. Also called E-Cigs, Personal Vaporizer. o Unknown-(SNOMED: TBD) An individual for whose tobacco product use is unknown. |
There are SNOMED and LOINC Codes for most of the data elements but new codes will be requested for eCigarette use. |
Anita walden | HL7 Common Clinical Registry Framework project | ||
| 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 Name | The name of 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 | 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 Performing Provider Name | The name of the Performing Provider. This is the lowest level of provider available (for example, if both individual and group are available, then the individual should be provided). |
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 PCP name | The name of the PCP Provider. |
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. |
Date Medication Administered | A specific date/time or interval of time during which the administration took place (or did not take place, when the 'notGiven' attribute is true). |
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 | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administered Code | A code (or set of codes) that specify the medication that was administered. |
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 | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administration Dose | The amount of the medication given at one administration event. |
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 | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administration Dose Units | The units of measure associated with the amount of medication given at one administration event |
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 | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administered Reason Reference | Reference to a condition that is the reason for the medication administration. |
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 | |
| Level 0 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
DME Orders | Medically necessary equipment (and the corresponding order) that a physician prescribes for use in a patient’s home, including wheelchairs, walkers, and hospital beds. |
The Centers for Medicare & Medicaid Services (CMS) annually updates a spreadsheet that contains a list of the HCPCS codes for DME MAC and Part B MAC jurisdictions to reflect codes that are either added or discontinued (deleted) each year. The jurisdiction list is an Excel file and is available at https://www.cms.gov/Center/Provider-Type/Durable-Medical-Equipment-DME-Center |
Matt Reid | American Medical Association | |
| Level 0 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Income | Patient income level |
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| 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 Operating Surgeon Name | The name of the operating surgeon. |
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. |
Service Facility Address | The address of the facility where the service occurred. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| 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. |
Domestic Life/ Instrumental Activities of Daily Living (IADLs) | This data element carries information on Domestic Life/IADL that is exchanged as observations. (Observations are characteristics that can be tested, measured, or observed and are communicated with a name-value pair structure). Domestic Life/IADL is a broad domain. Using the conceptual framework of the the International Classification of Function (ICF), it includes aspects such as preparing simple meals, cleaning living area, shopping, etc.. Notes: • This data element is constrained to health data represented in data structures for observations. Observations should be represented using terminologies supporting this conceptual model, such as LOINC, which is designed for this purpose. Representing problems, goals, and other types of information related to functioning should use other data class structures as appropriate. • Examples of Domestic Life/IADL concepts can be found in the ICF browser at: https://apps.who.int/classifications/icfbrowser • Examples of demonstrated use of Domestic Life/IADL data can be found in the PACIO FHIR Functional Status Implementation Guide which supports exchange of observation data such as make light hot meal, light daily housework, light shopping using assessments coded with LOINC. |
LOINC. LOINC is a freely available global standard that contains a well-developed model for representing variables, answer lists, and the collections that contain them.* Many clinical assessments, scales, and other observations related to functioning are present in LOINC, including all of the variables on the PAC assessments for SNFs, IRFs, LTCHs, and HHAs. Regenstrief operates a robust process for adding new content (including functioning assessment instruments) if key gaps are identified. *PMID: 22899966 |
Michelle Dougherty | Submitted on behalf of the CMS Data Element Library (DEL) Health IT Workgroup | |
| Level 0 | Goals | Desired state to be achieved by a patient. |
Outcome Reference | Details of what's changed (or not changed). |
HL7 FHIR |
Shelly Spiro | Pharmacy HIT Collaborative | |
| 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 Supervising Physician Name | The name of the Supervising Physician for the 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. |
Claim Prescribing Physician Name | The name of the provider who prescribed the pharmaceutical. |
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 Supervising Physician NPI | The National Provider Identifier assigned to the Supervising Physician for the admission |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Substance Use | Tobacco/Nicotine Use Start Age | The age of the individual when they started nicotine consumption/use. Question Prompt: Age started nicotine consumption/use. |
There are SNOMED and LOINC Codes for most of the data elements but new codes will be requested for eCigarette use. |
Anita walden | HL7 Common Clinical Registry Framework project |