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 | 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 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Date Medication Prescribed | The date when the prescription was initially written or authored. |
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 | 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 Network Status | Indicates that the Performing Provider has a contract with the Plan (regardless of the network) that is effective on the 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. |
Claim Prescribing Provider NPI | The identifier from NCPDP field # 411-DB (Prescriber ID) that identifies the National Provider Identifier (NPI) 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 Prescriber Contracting Status | Indicates the network status of the prescribing physician. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Procedures | Activity performed for or on a patient as part of the provision of care. |
Location of Procedure | Healthcare service location within a facility where the procedure was performed. |
Location of Procedure: HSLOC (https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/hsloc.html) Transmission-based precautions: SNOMED CT |
Sheila Abner | CDC/NHSN | |
| Level 0 | Procedures | Activity performed for or on a patient as part of the provision of care. |
Procedure Treatment Intent | The purpose of a treatment, or the desired effect or outcome resulting from the treatment. For example, a treatment may be intended to completely or partially eradicate a disease process by disrupting its underlying physiological processes, resulting in improvement in health; or a treatment may have no expectation of eradication but rather may be intended simply to delay the onset of more severe symptoms; or may be intended to prolong life without any expectation of cure. NOTE: Treatment Intent has also been submitted under the Medications data class |
SNOMED CT codes for therapeutic intent (qualifier value) |
Andre Quina | MITRE | |
| Level 0 | Newborn's Delivery Information | Apgar Score | APGAR score post-birth including scores at 1, 5 and 10 minutes. |
LOINC codes exist for each of the proposed data elements: 11884-4 - Gestational age Estimated 73766-8 - Place where birth occurred [US Standard Certificate of Live Birth] 64710-7 - Was your pregnancy a live birth, stillbirth, miscarriage, abortion, or ectopic pregnancy [PhenX] 8339-4 - Birth weight Measured 8305-5 - Body height --post partum 9272-6 - 1 minute Apgar Score 9274-2 - 5 minute Apgar Score 9271-8 - 10 minute Apgar Score |
Craig Newman | Altarum | ||
| Level 0 | Pregnancy Information | Number Fetal Deaths This Delivery | The number of fetal deaths in this delivery. |
LOINC codes exist for each of the proposed data elements: 69461-2 - Mother's body weight --at delivery 68493-6 - Prenatal visits for this pregnancy # 69044-6 - Date first prenatal visit 57722-1 - Birth plurality of Pregnancy 73772-6 - Number of fetal deaths delivered 73773-4 - Number of infants in this delivery delivered alive |
Craig Newman | Altarum | ||
| 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. |
Self-care | This data element carries information on Self-care that is exchanged as observations. (Observations are characteristics that can be tested, measured, or observed and are communicated with a name-value pair structure). Self-care is a broad domain. Using the conceptual framework of the the International Classification of Function (ICF), it includes aspects such as eating, caring for teeth, putting clothes on, 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 Self-care concepts can be found in the ICF browser at: https://apps.who.int/classifications/icfbrowser • Examples of demonstrated use of Self-care data can be found in the PACIO FHIR Functional Status Implementation Guide which supports exchange of observation data such as eating, oral hygiene, upper body dressing 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 | 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. |
Mobility | This data element carries information on Mobility that is exchanged as observations. (Observations are characteristics that can be tested, measured, or observed and are communicated with a name-value pair structure). Mobility is a broad domain. Using the conceptual framework of the International Classification of Function (ICF), it includes aspects such as rolling over, transferring, walking short distances, 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 Mobility concepts can be found in the ICF browser at: https://apps.who.int/classifications/icfbrowser • Examples of demonstrated use of Mobility data can be found in the PACIO FHIR Functional Status Implementation Guide which supports exchange of observation data such as roll left and right, car transfer, walk 10 feet 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 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Care Team Role | The functional role of a provider on a claim. |
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 Quit Age (LOINC: 63631-6) | The age of the individual when they stopped nicotine consumption/use. Question Prompt: Age stopped 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 | ||
| Level 0 | Substance Use | Pack-years | The patient’s pack-years of smoking, or the information needed to determine the pack-years (e.g., packs per day and years of smoking). |
Unified Code for Untis of Measure (UCUM) units for pack years and packs per day. There is also a LOINC code for packs per day (8663-7) and years smoked (88029-4). |
Kensaku Kawamoto, MD, PhD, MHS | University of Utah | ||
| Level 0 | Substance Use | Tobacco/Nicotine Quit Date | The date the individual when they stopped nicotine consumption/use. Business rule: If quit date is within the last 30 days there should be a full date. If not, partial dates are accepted, or if null look for Quit Age |
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 Attending Physician Name | The name of 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 | |
| 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 NPI | The identifier assigned to 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. |
Medication Prescribed Code | A code (or set of codes) that specify this medication, or a textual description if no code is available. |
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 Prescribed Dose | Indicates the amount of medication per dose that is to be used by the patient. |
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 | Outcomes | Adverse Event Date | When the event occurred |
adverse events are mapped to MedDRA terminology |
Mitra Rocca | Food and Drug Administration |