Additional Information Specification 0003
CDAR1AIS0010R010
Additional Information Specification 0010:
Drug Prior Authorization Attachment
Release 1.0
Based on HL7 CDA Standard Release 1.0,
with supporting LOINC® Tables
Draft - December 2006
This page intentionally blank
Table of Contents
1 Introduction 1
1.1 LOINC Codes and Structure 2
1.2 Revision History 4
1.3 Privacy Concerns in Examples 4
1.4 HL7 Attachment-CDA Document Variants 4
1.5 Request for Information versus Request for Service 4
2 LOINC Codes 5
2.1 Supporting Documentation 5
2.2 Scope Modification Codes 5
2.3 Special Considerations 5
2.4 Attachment Data Components 6
2.4.1 Drug Request - Unspecified Therapeutic Category Attachment 6
2.4.2 NSAIDS - COX2 Inhibitors Attachment 6
2.4.3 Growth Hormone Attachment 6
2.4.4 Proton Pump Inhibitors Attachment 7
2.4.5 Erectile Dysfunction (ED) Agents Attachment 7
2.4.6 Narcotic (OPIOID) Agonists Attachment 8
2.4.7 Imidazole - Related Antifungals Attachment 8
3 Drug Prior Authorization Attachment Value Tables 8
3.1 Drug Request - Unspecified Therapeutic Category (UTC) Service Value Table 9
3.2 NSAIDS - COX2 Inhibitors Value Table 12
3.3 Growth Hormone (GH) Value Table 15
3.4 Proton Pump Inhibitors (PPI) Value Table 23
3.5 Erectile Dysfunction (ED) Agents Value Table 27
3.6 Narcotic(Opioid) Agonists Value Table 32
3.7 Imidazole - Related Antifungals Value Table 37
4 Coding Examples 43
4.1 Scenario 43
4.1.1 Drug Prior Authorization Attachment, Human-Decision Variant (XML body) 44
4.1.2 Drug Prior Authorization Attachment, Human-Decision Variant (non-XML body) 49
4.1.3 Coded Drug Prior Authorization Attachment, Computer-Decision Variant 52
5 Response Code Sets 58
5.1 HL70136: Yes-No Indicator 58
5.2 HL79038: Drug Prescribed, Therapy Type 58
5.3 HL79039: UTC, Diagnosis Confirmed By 58
5.4 HL79040: Reason Prior Therapy Discontinued 59
5.5 HL79041: NSAIDS/PPI Related Concurrent Therapy, Type 59
5.6 HL79042: NSAID Use, Duration 59
5.7 HL79043: Yes-No-Unknown Indicator 59
5.8 HL79044: Radiology Diagnosis Confirmation, Study Type 60
5.9 HL79045: Laboratory Diagnosis Confirmation, Study/Test 60
5.10 HL79046: GH, Patient History – Documented Onset 60
5.11 HL79047: GH, Patient History Information – Hypothalmic Pituitary Disease Induced By 60
5.12 HL79048: Treatment Status 61
5.13 HL79049: GHD Childhood Information, Puberty Status 61
5.14 HL79050: GH Dysfunction Adult Information, Secondary Causes 61
5.15 HL79051: Nutritional Information, Assessment Indicator 61
5.16 HL79052: Parental Height, Availability Indicator 61
5.17 HL79053: Diagnosis Confirmation and Level of Treatment Needed, Procedure Employed 62
5.18 HL79054: Diagnosis Confirmation and Level of Treatment Needed, GERD By Endoscopy Type 62
5.19 HL79055: H-Pylori Information, Status 62
5.20 HL79056: H-Pylori Information, Confirmed By 62
5.21 HL79057: ED, Related Diagnosis Confirmation, Confirmed By 63
5.22 HL79058: ED, Patient History – Pulmonary Hypertension Functional Level 63
5.23 HL79059: ED, Patient History – Evaluation Type 63
5.24 HL79060: ED, Patient History – ED Related To 63
5.25 HL79061: ED, Treatment of Related Causes – Psychogenic Causes of ED Treatment 64
5.26 HL79062: ED, Treatment of Related Causes – Drug Induced Option 64
5.27 HL79063: ED Concurrent Therapy, Type 64
5.28 HL79064: Narcotic (Opioid) Agonists, Patient History – Pain Syndrome Source 64
5.29 HL79065: Narcotic (Opioid) Agonists, Patient History – Pain Syndrome History 65
5.30 HL79066: Narcotic (Opioid) Agonists, Patient History – Pain Syndrome Persistence 65
5.31 HL79067: Narcotic (Opioid) Agonists, Complicating Conditions 65
5.32 HL79068: Opioid Related Concurrent Pain Therapy, Opioid Level 65
5.33 HL79069: Drug Prescribed, Topical Therapy - Reason 66
5.34 HL79070: Imidazole – Related Antifungals, Diagnosis Confirmed By 66
5.35 HL79071: Fungal Infection Information, Location 66
5.36 HL79072: Immune Compromise Information, Cause 66
5.37 HL79073: Immune Compromise Information, Verified By 66
5.38 HL79074: Co-Morbid Condition Information, Liver Dysfunction – Confirmed By 67
5.39 HL79075: Level of Functional Impairment 67
5.40 HL79076: Imidazole – Related Antifungals, Prior Therapy Type 67
5.41 I9C : ICD-9-CM 67
5.42 IC10: ICD-10-CM 67
5.43 iso+: Extended ISO Units Codes 68
5.44 NDC: National Drug Code 68
5.45 RXNC: RxNorm SCD (Semantic Clinical Drug) 68
5.46 RXNB: RxNorm SBD (Semantic Branded Drug) 68
5.47 DEA: Drug Enforcement Administration 68
5.48 HCI: HCIdea 69
5.49 NPI: National Provider Identifier 69
5.50 PTX: Health Care Provider Taxonomy 70
5.51 Miscellaneous OID References 70
5.51.1 Unique Instance Identifier 70
5.51.2 person_name.type_cd 70
5.51.3 Proprietary Provider ID 70
5.51.4 Example OID 70
Index of Tables and Figures
Table 1.1 Relationship of LOINC Codes, X12N Transactions, and HL7 CDA Documents. 3
Table 2.1 LOINC codes for a complete Drug Prior Authorization attachment data set 5
Table 2.4.1 Data Components for Drug Request - Unspecified Therapeutic Category (UTC) Attachment 6
Table 2.4.2 Data Components for NSAIDS - COX2 Inhibitors Attachment 6
Table 2.4.3 Data Components for Growth Hormone (GH) Attachment 6
Table 2.4.4 Data Components for Proton Pump Inhibitors (PPI) Attachment 7
Table 2.4.5 Data Components for Erectile Dysfunction Agents Attachment 7
Table 2.4.6 Data Components for Narcotic Agonists Attachment 8
Table 2.4.7 Data Components for Imidazole - Related Antifungals Attachment 8
Table 3.1 Drug Request - Unspecified Therapeutic Category Value Table 9
Table 3.2 NSAIDS - COX2 Inhibitors Value Table 12
Table 3.3 Growth Hormone Value Table 15
Table 3.4 Proton Pump Inhibitors Value Table 23
Table 3.5 Erectile Dysfunction Agents Value Table 27
Table 3.6 Narcotic(Opioid) Agonists Value Table 32
Table 3.7 Imidazole - Related Antifungals Value Table 37
Figure 4.1 Drug Prior Authorization Additional Data 43
Example 4.1.1 Drug Prior Authorization Attachment, Human-Decision Variant (XML body) 44
Figure 1. Rendered Human-Decision Variant (XML body) 46
Example 4.1.2 Drug Prior Authorization Attachment, Human-Decision Variant (non-XML body) 49
Figure 2. Rendered Human-Decision Variant (non-XML body) 50
Example 4.1.2 Drug Prior Authorization Attachment, Computer-Decision Variant 52
Figure 3. Rendered Human-Decision Variant (non-XML body) 56
Table 5.1 Yes-No Indicator 58
Table 5.2 Drug Prescribed, Therapy Type 58
Table 5.3 UTC, Diagnosis Confirmed By 58
Table 5.4 Reason Prior Therapy Discontinued 59
Table 5.5 NSAIDS – COX 2 Inhibitors, Concurrent Therapy - Type 59
Table 5.6 NSAID Use, Duration 59
Table 5.7 HL7 NSAID Use, Duration 59
Table 5.8 Radiology Diagnosis Confirmation, Study Type 60
Table 5.9 Laboratory Diagnosis Confirmation, Study/Test 60
Table 5.10 GH, Patient History – Documented Onset 60
Table 5.11 GH, Patient History Information – Hypothalmic Pituitary Disease Induced By 60
Table 5.12 Treatment Status 61
Table 5.13 GHD Childhood Information, Puberty Status 61
Table 5.14 GH Dysfunction Adult Information, Secondary Causes 61
Table 5.15 Nutritional Information, Assessment Indicator 61
Table 5.16 Parental Height, Availability Indicator 62
Table 5.17 Diagnosis Confirmation and Level Treatment Needed, Procedure Employed 62
Table 5.18 Diagnosis Confirmation and Level of Treatment Needed, GERD By Endoscopy Type 62
Table 5.19 H-Pylori Information, Status 62
Table 5.20 H-Pylori Information, Confirmed By 62
Table 5.21 ED, Related Diagnosis Confirmation, Confirmed By 63
Table 5.22 ED, Patient History – Pulmonary Hypertension Functional Level 63
Table 5.23 ED, Patient History – Evaluation Type 63
Table 5.24 ED, Patient History – ED Related To 63
Table 5.25 ED, Treatment of Related Causes – Psychogenic Causes of ED Treatment 64
Table 5.26 ED, Treatment of Related Causes – Drug Induced Option 64
Table 5.27 ED Concurrent Therapy, Type 64
Table 5.28 Narcotic (Opioid) Agonists, Patient History – Pain Syndrome Source 64
Table 5.29 Narcotic (Opioid) Agonists, Patient History – Pain Syndrome History 65
Table 5.30 Narcotic (Opioid) Agonists, Patient History – Pain Syndrome Persistance 65
Table 5.31 Narcotic (Opioid) Agonists, Complicating Conditions 65
Table 5.32 Opioid Concurrent Pain Therapy, Opioid Level 65
Table 5.33 Drug Prescribed, Topical Therapy - Reason 66
Table 5.34 Imidazole – Related Antifungals, Diagnosis Confirmed By 66
Table 5.35 Fungal Infection Information, Location 66
Table 5.36 Immune Compromise Information, Cause 66
Table 5.37 Immune Compromise Information, Verified By 66
Table 5.38 Co-Morbid Condition Information, Liver Dysfunction – Confirmed By 67
Table 5.39 Level of Functional Impairment 67
Table 5.40 Imidazole – Related Antifungals, Prior Therapy Type 67
Introduction
This publication provides the LOINC®[1] code values specific to a Drug Prior Authorization attachment for the following applications.
• Those codes that define the attachment or attachment components used in transactions such as those defined by the ASC X12N 278 (005010X215) Health Care Services Review Response and the ASC X12N 275 (005010X215) Additional Information to Support a Health Care Services Review Implementation Guides which are products of the insurance subcommittee, X12N, of Accredited Standards Committee X12.[2],[3]
• All of the codes may be used in HL7 Clinical Document Architecture (CDA) documents designed for inclusion in the BIN segment of the 275 transaction as described in the HL7 Additional Information Specification Implementation Guide[4]
The format of this document and the methods used to arrive at its contents are prescribed in the HL7 Additional Information Specification Implementation Guide.
Additional Information Specification 0010: Drug Prior Authorization Attachment is designed to facilitate the transmission of information necessary to evaluate and support the medical necessity for a drug being ordered for a patient. As the deployment of e-Prescribing and Electronic Health Records expands and the technology matures, it is anticipated that this AIS will become an integral part of a fully automated prescription, authorization and delivery process. Most health plans make use of a prior authorization process, either for specified classes of drugs or for atypical use of a drug. The attachment component specifications included represent the most commonly requested documentation requirements. These were developed in collaboration with the National Council for Prescription Drug Programs (NCPDP), Work Group 11 Prescriber/Pharmacist Interface, Prior Authorization Transfer Task Group. Additional components will be developed as the industry needs are assessed and defined.
Section 2 of this document defines the LOINC codes used to request Drug Prior Authorization attachments and the LOINC codes of each component in an attachment. Section 3 further describes each component of the Drug Prior Authorization attachment, the cardinality of the components and their answer parts, and the description, data types, codes, and units of each answer part.
Section 4 presents coding examples, with a narrative scenario, an XML example, and a display image of each example attachment using a popular browser. Section 5 further describes the code sets used in the response to each answer part of the attachment.
Note: All LOINC codes and descriptions are copyrighted by the Regenstrief Institute, with all rights reserved. See .
1 LOINC Codes and Structure
LOINC codes are used for several purposes:
• In the X12N 278 transaction set, LOINC codes identify the attachment or attachment components being requested to support a claim or encounter.
• In the HL7 CDA document, LOINC codes are used to identify the attachment, the attachment components, and their answer parts. This is returned in the X12N 275 transaction set.
• LOINC modifier codes may be used in the 278 transaction to further define the specificity of a request.
Table 1.1 Relationship of LOINC Codes, X12N Transactions, and HL7 CDA Documents.
| |X12N 278 |X12N 275 |HL7 CDA |
|Purpose of |Health Care Services Review |Additional Information to |Provide controlled content for X12N |
|Attachment |Response |Support a Health Care |275 BIN segment |
| | |Services Review | |
|LOINC Modifier |Used in the STC segment to limit|Reiterated in the STC |Not used in the CDA document |
|Codes |the scope or time frame of a |segment | |
| |request for information. e.g., | | |
| |Send information for up to 90 | | |
| |days before the related request.| | |
|LOINC Attachment |Used in the STC segment to |Reiterated in the STC |Used in the |
|Identifier |request an attachment in its |segment |element of the header |
| |entirety, e.g., | | |
| |Send the Proton Pump Inhibitors | | |
| |Attachment. | | |
|LOINC Attachment |Used in the STC segment to |Reiterated in the STC |Used in the computer-decision CDA |
|Component |request a specific attachment |segment |variant in the element |
| |component or part of a clinical | |of a to identify the |
| |report, .e.g., | |attachment component being provided, |
| |Send the H-Pylori Treatment | |e.g., |
| |Information | |This is information regarding |
| | | |H-Pylori Treatment. |
|LOINC Attachment |Not used in the 278 |Not used in the 275 except |Used in the computer-decision CDA |
|Component Answer | |within the CDA instance |variant in the element |
|Part | |document in the BIN |of a , an element |
| | |segment. |within a or a element |
| | | |within a to identify the |
| | | |answer part of an attachment |
| | | |component being provided, e.g., |
| | | |This is the patient’s current height.|
2 Revision History
|Date |Purpose |
|Initial Release for Review|December 2005 |
|First Ballot |March 2006 |
| | |
| | |
| | |
| | |
3 Privacy Concerns in Examples
The names of natural persons that appear in the examples of this book are intentionally fictional. Any resemblance to actual natural persons, living or deceased is purely coincidental.
4 HL7 Attachment-CDA Document Variants
As described in the HL7 Additional Information Specification Implementation Guide, there are two variants of a CDA document when used as an attachment.
The human-decision variant is used solely for information that will be rendered for a person to look at, in order to make a decision. HL7 provides a non-normative style sheet for this purpose. There are two further alternatives within the human-decision variant.
• non_xml body: The information can be sent with a CDA header structured in XML, along with a "non_xml body" that references scanned images of documents that contain the submitted information
• xml body: the information can be sent as free text in XML elements that organize the material into sections, paragraphs, tables and lists as described in the HL7 Additional Information Specification Implementation Guide.
The computer-decision variant has the same content as the human-decision variant, but additional coded and structured information is included so that a computer could provide decision support based on the document. Attachments in the computer-decision variant can be rendered for human decisions using the same style sheet that HL7 provides for rendering documents formatted according to the human-decision variant.
5 Request for Information versus Request for Service
This attachment specification for Drug Prior Authorization defines a “send-me-what-you-have” attachment. It asks for a set of Drug Prior Authorization attachment components needed for the Drug Prior Authorization process. It is not asking for any additional data capture efforts. For example, if the request for data is to send the length of time the patient is expected to need the medication at the requested dose level, it is not asking the provider to obtain additional information if they don’t already have this information.
In any attachment component answer part it may sometimes be impossible to send a required answer and necessary to send, instead, a reason why the information is not available. In the human decision variant the sender shall supplement the natural language explanation of why the information is not available with local markup. In the computer-decision variant the sender shall include local markup to describe the reason that the information is not available as described in the Data Types section of the HL7 Additional Information Specification Implementation
LOINC Codes
1 Supporting Documentation
Table 2.1 defines the LOINC codes used to request a complete attachment data set for Drug Prior Authorization. The use of any of these codes in the 278 HI or PWK segments represents an explicit request for the complete set of data components relevant to the drug prior authorization.
The provider shall return all data components for which data is available.
The provider may choose to return images of pages that constitute the requested information by using the element of the CDA as described in the HL7 Additional Information Specification Implementation Guide.
The set of data components for the Drug Prior Authorization attachment, identified by individual LOINC codes, is defined in Section 2.4.
NOTE: The LOINC values represented in this draft ballot version are included as representative examples and are not the actual LOINC values that will be used for this attachment. Once the AIS has been approved, the actual LOINC values will be requested from Regenstrief and included in the final published version. The final check digit (after the hyphen) indicates for example purposes only, the specific drug attachment category. Where a component or answer part is re-used in the document, the sample LOINC value is repeated to indicate this re-use. The final check digit will be an “x” to indicate that it is used in more than one drug attachment category.
Table 2.1 LOINC codes for a complete Drug Prior Authorization attachment data set
|LOINC code |Attachment Name |
|99999-1 |Drug Request – Unspecified Therapeutic Category Attachment |
|99999-2 |NSAIDS – COX2 Inhibitors Attachment |
|99999-3 |Growth Hormone Attachment |
|99999-4 |Proton Pump Inhibitors Attachment |
|99999-5 |Erectile Dysfunction Agents Attachment |
|99999-6 |Narcotic (Opioid) Agonists Attachment |
|99999-7 |Imidazole – Related Antifungals Attachment |
2 Scope Modification Codes
The HL7 publication LOINC Modifier Codes (for use with ASC X12N Implementation Guides when Requesting Additional Information) provides code values for further defining the specificity of a request for additional information. Both time window and item selection modifier codes are defined. This publication is available from HL7, and is in the download package with the AIS documents.
3 Special Considerations
Intentionally left blank.
4 Attachment Data Components
Individual LOINC codes are defined for each data component of the attachment specific to the therapeutic drug category listed in Table 2.1. These LOINC codes are listed in sections 2.4.1 to 2.4.7 respectively. For example, the data components comprising the cardiac rehabilitation attachment (LOINC 18824-3) appear in Table 2.4.2. Each table is headed by the LOINC code defining the complete attachment.
The LOINC codes in Table 2.1 represent requests for complete Drug Prior Authorization attachments. However, the requester also has the option of focusing on a specific component of the attachment through the use of the LOINC codes defined in the following tables. In this case the provider will respond with information, where available, specific to the requested data components.
These LOINC codes may be used in ASC X12N 278 as defined in the associated Implementation Guide and will be mirrored in the corresponding ASC X12N 275 response. In addition, these LOINC codes are used in the element of the computer-decision variant of HL7 Additional Information Specification Implementation Guide. The questions that these LOINC codes represent are the result of a significant industry outreach project and represent the complete set of Drug Prior Authorization attachment components at this time. Additional drug therapeutic categories may be added to this document at a later date.
1 Drug Request - Unspecified Therapeutic Category Attachment
Table 2.4.1 Data Components for Drug Request - Unspecified Therapeutic Category (UTC) Attachment
|LOINC Code |Description |
|99999-1 |DRUG REQUEST - UNSPECIFIED THERAPEUTIC CATEGORY ATTACHMENT |
|90010-x |PRESCRIBER INFORMATION (COMPOSITE) |
|90020-x |PRESCRIBER CONTACT INFORMATION (COMPOSITE) |
|90030-x |DRUG PRESCRIBED (COMPOSITE) |
|90040-1 |UTC, MEDICAL NECESSITY INFORMATION |
|90050-1 |UTC, RELATED DIAGNOSIS INFORMATION (COMPOSITE) |
|90060-1 |UTC, ADDITIONAL CONFIRMATION INFORMATION |
|90070-x |MEDICARE ESRD CERTIFICATION DATE |
|90080-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS (COMPOSITE) |
|90090-x |CONCURRENT THERAPY (COMPOSITE) |
2 NSAIDS - COX2 Inhibitors Attachment
Table 2.4.2 Data Components for NSAIDS - COX2 Inhibitors Attachment
|LOINC Code |Description |
|99999-2 |NSAIDS - COX2 INHIBITORS ATTACHMENT |
|90010-x |PRESCRIBER INFORMATION (COMPOSITE) |
|90020-x |PRESCRIBER CONTACT INFORMATION (COMPOSITE) |
|90030-x |DRUG PRESCRIBED (COMPOSITE) |
|90100-2 |NSAIDS-COX2 INHIBITORS, RELATED DIAGNOSIS |
|90080-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS (COMPOSITE) |
|90090-x |CONCURRENT THERAPY (COMPOSITE) |
|90110-x |NSAIDS/PPI RELATED CONCURRENT THERAPY (COMPOSITE) |
|90120-2 |NSAID USE (COMPOSITE) |
3 Growth Hormone Attachment
Table 2.4.3 Data Components for Growth Hormone (GH) Attachment
|LOINC Code |Description |
|99999-3 |GROWTH HORMONE ATTACHMENT |
|90010-x |PRESCRIBER INFORMATION (COMPOSITE) |
|90020-x |PRESCRIBER CONTACT INFORMATION (COMPOSITE) |
|90030-x |DRUG PRESCRIBED (COMPOSITE) |
|90130-3 |GH, RELATED DIAGNOSIS |
|90140-3 |RADIOLOGICAL DIAGNOSIS CONFIRMATION INFORMATION (COMPOSITE) |
|90150-3 |LABORATORY DIAGNOSIS CONFIRMATION INFORMATION (COMPOSITE) |
|90160-3 |GH, PATIENT HISTORY INFORMATION (COMPOSITE) |
|90170-3 |GHD CHILDHOOD INFORMATION (COMPOSITE) |
|90180-3 |GH DYSFUNCTIONADULT INFORMATION (COMPOSITE) |
|90190-3 |WASTING SYNDROME INFORMATION (COMPOSITE) |
|90200-3 |NUTRITIONAL INFORMATION (COMPOSITE) |
|90210-3 |LABORATORY GH STIMULATION (COMPOSITE) |
|90220-3 |PHYSICIAL FINDINGS, PATIENT HEIGHT (COMPOSITE) |
|90230-3 |PHYSICIAL FINDINGS, PATIENT WEIGHT (COMPOSITE) |
|90240-3 |PATIENT BODY MASS INDEX (COMPOSITE) |
|90250-3 |PARENTAL HEIGHT (COMPOSITE) |
|90080-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS (COMPOSITE) |
|90090-x |CONCURRENT THERAPY (COMPOSITE) |
4 Proton Pump Inhibitors Attachment
Table 2.4.4 Data Components for Proton Pump Inhibitors (PPI) Attachment
|LOINC Code |Description |
|99999-4 |PROTON PUMP INHIBITORS ATTACHMENT |
|90010-x |PRESCRIBER INFORMATION (COMPOSITE) |
|90020-x |PRESCRIBER CONTACT INFORMATION (COMPOSITE) |
|90030-x |DRUG PRESCRIBED (COMPOSITE) |
|90260-4 |PPI, RELATED DIAGNOSIS |
|90270-4 |DIAGNOSIS CONFIRMATION AND LEVEL OF TREATMENT NEEDED (COMPOSITE) |
|90280-4 |PPI, PATIENT HISTORY – STRICTURE PRESENT |
|90080-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS (COMPOSITE) |
|90090-x |CONCURRENT THERAPY (COMPOSITE) |
|90110-x |NSAIDS/PPI RELATED CONCURRENT THERAPY (COMPOSITE) |
|90290-4 |H-PYLORI INFORMATION (COMPOSITE) |
|90300-4 |H-PYLORI TREATMENT (COMPOSITE) |
5 Erectile Dysfunction (ED) Agents Attachment
Table 2.4.5 Data Components for Erectile Dysfunction Agents Attachment
|LOINC Code |Description |
|99999-5 |ERECTILE DYSFUNCTION AGENTS ATTACHMENT |
|90010-x |PRESCRIBER INFORMATION (COMPOSITE) |
|90020-x |PRESCRIBER CONTACT INFORMATION (COMPOSITE) |
|90030-x |DRUG PRESCRIBED (COMPOSITE) |
|90310-5 |ED, RELATED DIAGNOSIS |
|90320-5 |ED, RELATED DIAGNOSIS CONFIRMATION INFORMATION (COMPOSITE) |
|90330-5 |ED, PATIENT HISTORY INFORMATION (COMPOSITE) |
|90340-5 |ED, TREATMENT OF RELATED CAUSES (COMPOSITE) |
|90080-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS (COMPOSITE) |
|90090-x |CONCURRENT THERAPY (COMPOSITE) |
|90340-5 |ED RELATED CONCURRENT THERAPY (COMPOSITE) |
6 Narcotic (OPIOID) Agonists Attachment
Table 2.4.6 Data Components for Narcotic Agonists Attachment
|LOINC Code |Description |
|99999-6 |NARCOTIC (OPIOID) AGONISTS ATTACHMENT |
|90010-x |PRESCRIBER INFORMATION (COMPOSITE) |
|90020-x |PRESCRIBER CONTACT INFORMATION (COMPOSITE) |
|90030-x |DRUG PRESCRIBED (COMPOSITE) |
|90360-6 |NARCOTIC (OPIOID) AGONISTS, RELATED DIAGNOSIS |
|90370-6 |NARCOTIC (OPIOID) AGONISTS, PATIENT HISTORY (COMPOSITE) |
|90380-6 |NARCOTIC (OPIOID) AGONISTS, COMPLICATING CONDITIONS INFORMATION (COMPOSITE) |
|90390-6 |NARCOTIC (OPIOID) AGONISTS, LABORATORY INFORMATION (COMPOSITE) |
|90080-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS (COMPOSITE) |
|90090-x |CONCURRENT THERAPY (COMPOSITE) |
|90400-6 |OPIOD RELATED CONCURRENT PAIN THERAPY (COMPOSITE) |
|90410-6 |NARCOTIC (OPIOID) AGONISTS, USE FOR TREATMENT OF OPIOID ADDICTION |
7 Imidazole - Related Antifungals Attachment
Table 2.4.7 Data Components for Imidazole - Related Antifungals Attachment
|LOINC Code |Description |
|99999-7 |IMIDAZOLE - RELATED ANTIFUNGALS ATTACHMENT |
|90010-x |PRESCRIBER INFORMATION (COMPOSITE) |
|90020-x |PRESCRIBER CONTACT INFORMATION (COMPOSITE) |
|90030-x |DRUG PRESCRIBED (COMPOSITE) |
|90420-7 |DRUG PRESCRIBED, TOPICAL THERAPY (COMPOSITE) |
|90430-7 |IMIDAZOLE - RELATED ANTIFUNGALS, RELATED DIAGNOSIS INFORMATION (COMPOSITE) |
|90440-7 |FUNGAL INFECTION INFORMATION (COMPOSITE) |
|90450-7 |IMMUNE COMPROMISE INFORMATION (COMPOSITE) |
|90460-7 |CO-MORBID CONDITION INFORMATION (COMPOSITE) |
|90070-x |MEDICARE ESRD CERTIFICATION DATE |
|90470-7 |LEVEL OF FUNCTIONAL IMPAIRMENT |
|90480-7 |INPATIENT TREATMENT Information (COMPOSITE) |
|90080-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS (COMPOSITE) |
|90490-7 |IMIDAZOLE - RELATED ANTIFUNGALS, PRIOR THERAPY TYPE |
|90090-x |CONCURRENT THERAPY (COMPOSITE) |
Drug Prior Authorization Attachment Value Tables
Each of the tables in this section further describes the LOINC components listed in the above corresponding table, along with the expected answer part(s) for each question, including the data type, cardinality, and codes/units for each answer.
The minimum attachment data set equates to the required components; those identified in the value table, below, with cardinality (Card) of
{1,1} (component is required and has one and only one occurrence) or
{1,n} (component is required and has one or more occurrences).
Those data components with a cardinality of
{0,1} (if available has one and only one occurrence) or
{0,n} (if available may have one or more occurrences)
shall be sent if available.
1 Drug Request - Unspecified Therapeutic Category (UTC) Service Value Table
Table 3.1 Drug Request - Unspecified Therapeutic Category Value Table
|LOINC code |Value |Data Type |Card |Response Code |
|Component Answer | | | |/ Numeric Units |
|90010-x |PRESCRIBER INFORMATION | |1,1 | |
| |Information about the practitioner prescribing the drug. | | | |
|90011-x |PRESCRIBER INFORMATION, NAME |PN |1,1 | |
| |This is the name of the practitioner prescribing the drug. | | | |
|90012-x |PRESCRIBER INFORMATION, IDENTIER |CX |1,n |NPI |
| |This may be repeated to convey multiple identifiers such as the | | |DEA |
| |National Provider Identifier (NPI), Drug Enforcement Act number (DEA),| | |HCIdea |
| |Special DEA number, HCIdea Number or proprietary provider identifier.| | |Proprietary Provider|
| | | | |ID |
| |Note: If the provider is a covered entity under HIPAA and the NPI is | | | |
| |mandated for use, the NPI must be sent as one of the identifiers and | | |See note at left. |
| |the legacy provider identifier must not be used. | | | |
|90013-x |PRESCRIBER INFORMATION, SPECIALTY TAXONOMY CODE |CE |1,1 |PTX |
| |This is the Taxonomy code that represents the medical specialty of the| | | |
| |prescriber. | | | |
|90020-x |PRESCRIBER CONTACT INFORMATION | |0,1 | |
| |Contact information for the individual prescribing the drug. | | | |
|90021-x |PRESCRIBER CONTACT INFORMATION, PHONE NUMBER |TX |1,1 | |
| |The phone number of the individual prescribing the drug. | | | |
|90022-x |PRESCRIBER CONTACT INFORMATION, FAX NUMBER |TX |0,1 | |
| |The fax number of the individual prescribing the drug. | | | |
|90030-x |DRUG PRESCRIBED | |1,1 | |
| |This is information about the drug requested in the prior | | | |
| |authorization. | | | |
|90031-x |DRUG PRESCRIBED, NAME |TX |1,1 | |
| |This is the descriptive name of the drug prescribed. | | | |
|90032-x |DRUG PRESCRIBED, DRUG CODE |CE |1,1 |NDC |
| |This is the code identifier for the drug prescribed as defined by | | |RxNorm SCD |
| |Representative NDC, RxNorm SCD or RxNorm SBD. | | |RxNorm SBD |
|90033-x |DRUG PRESCRIBED, THERAPY TYPE |CE |1,1 |HL79038 |
| |This is used to convey the historical use of the prescribed drug as | | | |
| |part of the patient’s therapy. | | | |
| | | | | |
| |INTRQ Initial Therapy | | | |
| |CNTRQ Continued Therapy | | | |
| |RPLRQ Replacement Therapy | | | |
| |ADDRQ Add on Therapy | | | |
| |DRUG PRESCRIBED, SELF ADMINISTERED INDICATOR | |0,1 |HL70136 |
|90034-x |This indicator defines if the drug can be self administered. | | | |
| | | | | |
| |N No | | | |
| |Y Yes | | | |
|90040-1 |UTC, MEDICAL NECESSITY INFORMATION | |0,1 | |
| |Additional information as required to support the medical necessity of| | | |
| |the requested medication therapy. This is submitted based on the plan | | | |
| |or UMO's defined requirements for the drug. | | | |
| | |TX |1,1 | |
|90040-1 | | | | |
|90050-1 |UTC, RELATED DIAGNOSIS INFORMATION | |1,1 | |
| |Diagnosis information related to the prescribed drug. | | | |
|90051-1 |UTC, RELATED DIAGNOSIS |CE |1,1 |IC9 |
| |This is the related diagnosis of the patient for which the drug is a | | |IC10 |
| |prescribed therapy. | | | |
| | | | | |
| |Note: Prior to U.S. adoption of ICD-10-CM, use ICD-9-CM in the U.S. | | | |
| |domain. After adoption as the standard for defining diagnoses in the | | | |
| |US, use only ICD-10-CM for requests in the US. | | | |
| 90052-1 |UTC, DIAGNOSIS CONFIRMED BY |CE |0,n |HL79039 |
| |This conveys the means by which the diagnosis was established- | | | |
| |diagnostic procedures and/or clinical observation. | | | |
| | | | | |
| |LABT Laboratory Examination | | | |
| |RADT Radiological Examination | | | |
| |OTDX Other Diagnostic Examination | | | |
| |CLNE Clinical Evaluation | | | |
|90053-1 |UTC, DIAGNOSIS CONFIRMED BY – DATE OF CLINICAL EVALUATION |DT |01 | |
| |This is the date the confirmatory clinical evaluation was performed. | | | |
|90060-1 |UTC, ADDITIONAL confirmation information | |0,n | |
| |This is used to convey information about the diagnostic study used to | | | |
| |confirm the diagnosis. It is required when the answer to Unspecified | | | |
| |Therapeutic Category, Diagnosis Confirmed By is equal to “LABT” | | | |
| |Laboratory Examination, “RADT” Radiological Examination, or “OTDX” | | | |
| |Other Diagnostic Examination. | | | |
| |UTC, additional CONFIRMATION information - Name of TesT |TX |0,1 | |
|90061-1 |This is used to convey the name of the diagnostic study used to | | | |
| |confirm the diagnosis. | | | |
| |UTC, ADDITIONAL confirmation information - TesT RESULT |NM |0,1 |iso+ |
|90062-1 |This is the result of the diagnostic procedure by which the diagnosis | | |ans+ |
| |was confirmed. It is required when the answer to Unspecified | | | |
| |Therapeutic Category, Diagnosis Confirmed By is equal to “LABT” | | | |
| |Laboratory Examination. | | | |
| |UTC, additional CONFIRMATION information - DATE of TesT OR OBSERVATION|DT |1,1 | |
|90063-1 |This is the date the confirmatory diagnostic study. | | | |
|90070-x |MEDICARE ESRD CERTIFICATION DATE | |0,1 | |
| |The date the patient was certified by Medicare as having End Stage | | | |
| |Renal Disease. | | | |
|90070-x | |DT |1,1 | |
|90080-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS | |0,n | |
| |Information about other drugs previously prescribed for treatment of | | | |
| |this condition with less than optimal outcomes. | | | |
|90081-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG NAME |TX |1,1 | |
| |This is the descriptive name of the drug previously used to treat the | | | |
| |diagnosis. | | | |
|90082-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS, - DRUG CODE |CE |1,1 |NDC |
| |The code assigned to the drug previously used to treat the diagnosis | | |RxNorm SCD |
| |as defined by: Representative NDC, RxNorm SCD, or RxNorm SBD. | | |RxNorm SBD |
|90083-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DURATION OF THERAPY |NM |1,1 |iso+ |
| |Duration of previous therapy in days. | | | |
|90084-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR THERAPY |CE |1,1 |HL79040 |
| |DISCONTINUED | | | |
| |Reason prior drug therapy was discontinued. | | | |
| | | | | |
| |NTEFF Not or No Longer Effective | | | |
| |SDEFT Side Effects/Tolerance | | | |
| |NTCMP Not Compatible | | | |
| |OTH Other | | | |
|90085-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR THERAPY |TX |0,1 | |
| |DISCONTINUED, OTHER | | | |
| |If Drug History, Prior Therapy for Diagnosis - Reason Prior Therapy | | | |
| |Discontinued is equal to “OTH” Other, then this is required. | | | |
|90086-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS – REASON PRIOR THERAPY |TX |0,n | |
| |DISCONTINUED, INCOMPATIBLE DRUG NAME | | | |
| | | | | |
| |The descriptive name of the drug incompatible with the prior therapy. | | | |
| |If Drug History, Prior Therapy for Diagnosis – Reason Prior Therapy | | | |
| |Discontinued equals “NTCMP” Not Compatible, then this is required. | | | |
|90090-x |CONCURRENT THERAPY | |0,n | |
| |Drugs the patient is currently on, for this or other diagnoses, which | | | |
| |may impact the requested drug. | | | |
|90091-x |CONCURRENT THERAPY, DRUG NAME |TX |0,1 | |
| |The descriptive name of the drug used in concurrent therapy, for this | | | |
| |or other diagnoses, which may impact the requested drug. | | | |
|90092-x |CONCURRENT THERAPY, DRUG CODE |CE |1,1 |NDC |
| |The code assigned to the concurrent drug as defined by: | | |RxNorm SCD |
| |Representative NDC, RxNorm SCD, or RxNorm SBD. | | |RxNorm SBD |
| | | | | |
2 NSAIDS - COX2 Inhibitors Value Table
Table 3.2 NSAIDS - COX2 Inhibitors Value Table
|LOINC code |Value |Data Type |Card |Response Code |
|Component Answer | | | |/ Numeric Units |
|90010-x |PRESCRIBER INFORMATION | |1,1 | |
| |Information about the practitioner prescribing the drug. | | | |
|90011-x |PRESCRIBER INFORMATION, NAME |PN |1,1 | |
| |This is the name of the practitioner prescribing the drug. | | | |
|90012-x |PRESCRIBER INFORMATION, IDENTIER |CX |1,n |NPI |
| |This may be repeated to convey multiple identifiers such as the | | |DEA |
| |National Provider Identifier (NPI), Drug Enforcement Act number (DEA),| | |HCIdea |
| |Special DEA number, HCIdea Number or proprietary provider identifier.| | |Proprietary Provider|
| | | | |ID |
| |Note: If the provider is a covered entity under HIPAA and the NPI is | | | |
| |mandated for use, the NPI must be sent as one of the identifiers and | | |See note at left. |
| |the proprietary provider identifier must not be used. | | | |
|90013-x |PRESCRIBER INFORMATION, SPECIALTY TAXONOMY CODE |CE |1,1 |PTX |
| |This is the Taxonomy code that represents the medical specialty of the| | | |
| |prescriber. | | | |
|90020-x |PRESCRIBER CONTACT INFORMATION | |0,1 | |
| |Contact information for the individual prescribing the drug. | | | |
|90021-x |PRESCRIBER CONTACT INFORMATION, PHONE NUMBER |TX |1,1 | |
| |This is the phone number of the individual prescribing the drug. | | | |
|90022-x |PRESCRIBER CONTACT INFORMATION, FAX NUMBER |TX |0,1 | |
| |This is the fax number of the individual prescribing the drug. | | | |
|90030-x |DRUG PRESCRIBED | |1,1 | |
| |This is information about the drug requested in the prior | | | |
| |authorization. | | | |
|90031-x |DRUG PRESCRIBED, NAME |TX |1,1 | |
| |This is the descriptive name of the drug prescribed. | | | |
|90032-x |DRUG PRESCRIBED, DRUG CODE |CE |1,1 |NDC |
| |This is the code identifier for the drug prescribed as defined by | | |RxNorm SCD |
| |Representative NDC, Rx Norm SCD, or RxNorm SBD. | | |RxNorm SBD |
|90033-x |DRUG PRESCRIBED, THERAPY TYPE |CE |1,1 |HL79038 |
| |This is used to convey the historical use of the prescribed drug as | | | |
| |part of the patient’s therapy. | | | |
| | | | | |
| |INTRQ Initial Therapy | | | |
| |CNTRQ Continued Therapy | | | |
| |RPLRQ Replacement Therapy | | | |
| |ADDRQ Add on Therapy | | | |
|90034-x |DRUG PRESCRIBED, SELF ADMINISTERED INDICATOR | |0,1 |HL70136 |
| |This indicator defines if the drug can be self administered. | | | |
| | | | | |
| |N No | | | |
| |Y Yes | | | |
|90100-2 |NSAIDS-COX2 INHIBITORS, RELATED DIAGNOSIS | |1,1 | |
| |Diagnosis information related to the prescribed drug. | | | |
|90100-2 |NSAIDS-COX2 INHIBITORS, RELATED DIAGNOSIS |CE |1,1 |IC9 |
| |This is the related diagnosis of the patient for which the drug is a | | |IC10 |
| |prescribed therapy. | | | |
| | | | | |
| |Note: Prior to U.S. adoption of ICD-10-CM, use ICD-9-CM in the U.S. | | | |
| |domain. After adoption as the standard for defining diagnoses in the | | | |
| |US, use only ICD-10-CM for requests in the US. | | | |
|90080-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS | |0,n | |
| |Information about other drugs previously prescribed for treatment of | | | |
| |this condition with less than optimal outcomes. | | | |
|90081-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG NAME |TX |1,1 | |
| |This is the descriptive name of the drug previously used to treat the | | | |
| |diagnosis. | | | |
|90082-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG CODE |CE |1,1 |NDC |
| |The code assigned to the drug previously used to treat the diagnosis | | |RxNorm SCD |
| |as defined by: Representative NDC, RxNorm SCD, or RxNorm SBD. | | |RxNorm SBD |
|90083-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS, DURATION OF THERAPY |NM |1,1 |iso+ |
| |Duration of previous therapy in days. | | | |
|90084-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS, REASON PRIOR THERAPY |CE |1,1 |HL79040 |
| |DISCONTINUED | | | |
| |Reason prior drug therapy was discontinued. | | | |
| | | | | |
| |NTEFF Not or No Longer Effective | | | |
| |SDEFT Side Effects/Tolerance | | | |
| |NTCMP Not Compatible | | | |
| |OTH Other | | | |
|90085-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR THERAPY |TX |0,1 | |
| |DISCONTINUED, OTHER | | | |
| |Description of the other reason for discontinued therapy. If Drug | | | |
| |History, Prior Therapy for Diagnosis - Reason Prior Therapy | | | |
| |Discontinued equals "OTH" Other, then this is required. | | | |
|90086-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS – REASON PRIOR THERAPY |TX |0,n | |
| |DISCONTINUED, INCOMPATIBLE DRUG NAME | | | |
| |The descriptive name of the drug incompatible with the prior therapy. | | | |
| |If Drug History, Prior Therapy for Diagnosis – Reason Prior Therapy | | | |
| |Discontinued equals “NTCMP” Not Compatible, then this is required. | | | |
|90090-x |CONCURRENT THERAPY | |0,n | |
| |Drugs the patient is currently on, for this or other diagnoses, which | | | |
| |may impact the requested drug. | | | |
|90091-x |CONCURRENT THERAPY, DRUG NAME |TX |0,1 | |
| |The descriptive name of the drug used in concurrent therapy, for this | | | |
| |or other diagnoses, which may impact the requested drug. | | | |
|90092-x |CONCURRENT THERAPY, DRUG CODE |CE |1,1 |NDC |
| |The code assigned to the concurrent drug as defined by: | | |RxNorm SCD |
| |Representative NDC, RxNorm SCD, or RxNorm SBD | | |RxNorm SBD |
|90110-x |NSAIDS/PPI RELATED CONCURRENT THERAPY | |0,1 | |
| |NSAID/PPI related drugs being used concurrently with the requested | | | |
| |drug. | | | |
|90111-x |NSAIDS/PPI RELATED CONCURRENT THERAPY, TYPE |CE |1,1 |HL79041 |
| |Concurrent NSAIDS/PPI related drug therapies being used for treatment | | | |
| |of this or other conditions. | | | |
| | | | | |
| |See section 5 for the list of valid codes. | | | |
|90112-x |NSAIDS/PPI RELATED CONCURRENT THERAPY, OTHER TYPE |TX |0,1 | |
| |The descriptive name of the NSAIDS/PPI related drug(s) used in | | | |
| |concurrent therapy. Required when NSAIDS/PPI Related Concurrent | | | |
| |Therapy, Type equals “OTH” Other. | | | |
|90120-x |NSAID USE | |1,1 | |
| |Extended NSAID use and associated problems. | | | |
|90121-2 |NSAID USE, DURATION |CE |1,1 |HL79042 |
| |The length of time NSAID use is or has been required. | | | |
| | | | | |
| |G21 NSAID use greater than 21 days | | | |
| |L21 NSAID use less than 21 days | | | |
|90122-2 |NSAID USE, INDUCED GI RISK FACTORS |CE |1,1 |HL79043 |
| |Indicator of whether gastrointestinal risk factors are/have been | | | |
| |induced by NSAID use. | | | |
| | | | | |
| |Y Yes | | | |
| |N No | | | |
| |U Unknown | | | |
3 Growth Hormone (GH) Value Table
Table 3.3 Growth Hormone Value Table
|LOINC code |Value |Data Type |Card |Response Code |
|Component Answer | | | |/ Numeric Units |
|90010-x |PRESCRIBER INFORMATION | |1,1 | |
| |Information about the practitioner prescribing the drug. | | | |
|90011-x |PRESCRIBER INFORMATION, NAME |PN |1,1 | |
| |This is the name of the practitioner prescribing the drug. | | | |
|90012-x |PRESCRIBER INFORMATION, IDENTIER |CX |1,n |NPI |
| |This may be repeated to convey multiple identifications such as the | | |DEA |
| |National Provider Identifier (NPI0, the Drug Enforcement Act (DEA) | | |HCIdea |
| |number, Special DEA number, HCIdea number or proprietary identifier. | | |Proprietary Provider|
| | | | |ID |
| |Note: If the provider is a covered entity under HIPAA and the NPI is | | | |
| |mandated for use, the NPI must be sent as one of the identifiers and | | |See note at left. |
| |the legacy provider identifier must not be used. | | | |
|90013-x |PRESCRIBER INFORMATION, SPECIALITY TAXONOMY CODE |CE |1,1 |PTX |
| |This is the Taxonomy code that identifies the medical specialty of the| | | |
| |prescriber | | | |
|90020-x |PRESCRIBER CONTACT INFORMATION | |0,1 | |
| |Contact information for the individual prescribing the drug. | | | |
|90021-x |PRESCRIBER CONTACT INFORMATION, PHONE NUMBER |TX |1,1 | |
| |The phone number of the individual prescribing the drug. | | | |
|90023-x |PRESCRIBER CONTACT INFORMATION, FAX NUMBER |TX |0,1 | |
| |The fax number of the individual prescribing the drug. | | | |
|90030-x |DRUG PRESCRIBED | |1,1 | |
| |This is information about the drug requested in the prior | | | |
| |authorization. | | | |
|90031-x |DRUG PRESCRIBED, NAME |TX |1,1 | |
| |This is the descriptive name of the drug prescribed. | | | |
|90032-x |DRUG PRESCRIBED, DRUG CODE |CE |1,1 |NDC |
| |This is the code identifier for the drug prescribed as defined by: | | |RxNorm SCD |
| |Representative NDC, RxNorm SCD or RxNorm SBD | | |RxNorm SBD |
|90033-x |DRUG PRESCRIBED, THERAPY TYPE |CE |1,1 |HL79038 |
| |This is used to convey the historical use of the prescribed drug as | | | |
| |part of the patient's therapy. | | | |
| | | | | |
| |INTRQ Initial Therapy | | | |
| |CNTRQ Continued Therapy | | | |
| |RPLRQ Replacement Therapy | | | |
| |ADDRQ Add on Therapy | | | |
|90034-x |DRUG PRESCRIBED, SELF ADMINISTERED INDICATOR | |0,1 |HL70136 |
| |This indicator defines if the drug can be self administered. | | | |
| | | | | |
| |N No | | | |
| |Y Yes | | | |
|90130-3 |GH, RELATED DIAGNOSIS | |1,1 | |
| |This is the related diagnosis of the patient for which the drug is a | | | |
| |prescribed therapy. | | | |
| | | | | |
| |Note: Prior to U.S. adoption of ICD-10-CM, use ICD-9-CM in the U.S. | | | |
| |domain. After adoption as the standard for defining diagnoses in the | | | |
| |US, use only ICD-10-CM for requests in the US. | | | |
|90130-3 | |CE |1,1 |IC9 |
| | | | |IC10 |
|90140-3 |RADIOLOGICAL DIAGNOSIS CONFIRMATION INFORMATION | |0,n | |
| |Diagnostic procedures and criteria confirming the diagnosis and level | | | |
| |of treatment need. | | | |
|90141-3 |RADIOLOGY DIAGNOSIS CONFIRMATION INFORMATION, STUDY TYPE |CE |1,1 |HL79044 |
| |These are the radiological studies used to confirm the diagnosis. | | | |
| |Epiphyseal status or bone age is required for childhood growth hormone| | | |
| |deficiency.. | | | |
| | | | | |
| |BAE Bone Age | | | |
| |BDY Bone Density | | | |
| |MRI MRI | | | |
| |ESX X-Ray to Determine Epiphyseal Status | | | |
|90142-3 |RADIOLOGICAL DIAGNOSIS CONFIRMATION INFORMATION, STUDY RESULT |TX |1,1 | |
| |Result of the radiological study performed. Required when diagnosis is| | | |
| |confirmed by radiological study. | | | |
|90143-3 |RADIOLOGICAL DIAGNOSIS CONFIRMATION INFORMATION, STUDY DATE |DT |1,1 | |
| |Date the radiological study performed. Required when diagnosis | | | |
| |confirmed by radiological study. | | | |
|90150-3 |LABORATORY DIAGNOSIS CONFIRMATION INFORMATION | |0,n | |
| |Diagnostic procedures and criteria confirming the diagnosis and level | | | |
| |of treatment need. | | | |
|90151-3 |LABORATORY DIAGNOSIS CONFIRMATION INFORMATION, STUDY/TEST |CE |1,n |HL79045 |
| |These are laboratory studies used to confirm Growth Hormone | | | |
| |Deficiency/Dysfunction. | | | |
| | | | | |
| |See section 5 for a list of valid codes. | | | |
|90152-3 |LABORATORY DIAGNOSIS CONFIRMATION INFORMATION, OTHER STUDY/TEST NAME |TX |0,1 | |
| |This is used to convey the name of the other test used to confirm GHD.| | | |
| |It is required when Diagnosis Confirmation Information Laboratory | | | |
| |Confirmation equals "OTH" Other. | | | |
|90153-3 |LABORATORY DIAGNOSIS CONFIRMATION INFORMATION, STUDY/TEST RESULT |NM |1,1 |iso+ |
| |This is the result of laboratory study used to confirm the diagnosis. | | |ans+ |
|90154-3 |LABORATORY DIAGNOSIS CONFIRMATION INFORMATION, STUDY/TEST DATE |DT |1,1 | |
| |This is the date that the test confirming the diagnosis of GHD was | | | |
| |performed. | | | |
|90160-3 |GH, PATIENT HISTORY INFORMATION | |1,1 | |
| |Patient history related to the prescribed drug. | | | |
|90161-3 |GH, PATIENT HISTORY INFORMATION – DOCUMENTED ONSET |CE |0,1 |HL79046 |
| |Documented onset of hypothalamic pituitary disease or GH | | | |
| |deficiency/dysfunction. | | | |
| | | | | |
| |AO Adult Onset | | | |
| |CO Childhood Onset | | | |
| |UO Unknown Onset | | | |
|90162-3 |GH, PATIENT HISTORY INFORMATION – HYPOTHALMIC PITUITARY DISEASE |CE |0,n |HL79047 |
| |INDUCED BY | | | |
| |This describes conditions and/or treatments leading to HPD. | | | |
| | | | | |
| |PTT Pituitary Tumor | | | |
| |IRR Irradiation | | | |
| |SUG Surgery | | | |
| |HMN Hormone Dysfunction or Therapy | | | |
| |TRA Trauma | | | |
|90163-3 |GH, PATIENT HISTORY INFORMATION – GHD TREATMENT STATUS |CE |1,1 |HL79048 |
| |This describes the treatment status, i.e., whether GH Therapy has been| | | |
| |attempted in the past, is ongoing or is just begin. | | | |
| | | | | |
| |See section 5 for the list of valid codes. | | | |
|90164-3 |GROWTH HORMONE, PATIENT HISTORY INFORMATION – GHD TREATMENT DATE |DT |0,1 | |
| |This is the date the current/most current GH treatment initiated/to be| | | |
| |initiated. | | | |
|90170-3 |GROWTH HORMONE DEFICIENCY (GHD) CHILDHOOD INFORMATION | |0,1 | |
| |Information about growth hormone deficiency in childhood. | | | |
|90171-3 |GHD CHILDHOOD INFORMATION, SMALL FOR GESTATIONAL AGE INDICATOR |CE |0,1 |HL70136 |
| |This conveys information about the size of the child at birth, if | | | |
| |known. | | | |
| | | | | |
| |N No | | | |
| |Y Yes | | | |
|90172-3 |GHD CHILDHOOD INFORMATION, PUBERTY STATUS |CE |1,1 |HL79049 |
| |This information describes the status of the child relative to the | | | |
| |onset of puberty if known. | | | |
| | | | | |
| |BP Pre-pubertal | | | |
| |AP Post Pubertal | | | |
| |PS Pubertal | | | |
|90173-3 |GHD CHILDHOOD INFORMATION, THERAPY BY PEDIATRIC ENDOCRINOLOGIST OR |CE |1,1 |HL70136 |
| |NEPHROLOGIST INDICATOR | | | |
| |This conveys whether therapeutic intervention for the treatment of | | | |
| |childhood GHD is recommended and managed by a Pediatric | | | |
| |Endocrinologist or Nephrologists. | | | |
| | | | | |
| |N No | | | |
| |Y Yes | | | |
|90180-3 |GH DYSFUNCTION ADULT INFORMATION | |0,1 | |
| |This conveys information about Adult GH Dysfunction related to factors| | | |
| |other than endocrine disorders | | | |
| |GH Dysfunction Adult Information, Secondary Causes |CE |1,n |HL79050 |
|90181-3 |This conveys information about Adult GH Dysfunction related to factors| | | |
| |other than endocrine disorders. | | | |
| | | | | |
| |A Age | | | |
| |O Obesity | | | |
| |D Depression | | | |
| |OTH Other | | | |
| |GHD Dysfunction Adult Information, Other SECONDARY CAUSES |TX |0,1 | |
|90182-3 |Description of the other causes of adult GH dysfunction. Required when| | | |
| |GH Dysfunction Adult, Secondary Causes equals "OTH" other. | | | |
|90190-3 |WASTING SYNDROME INFORMATION | |1,1 | |
| |This provides information about the patient's concurrent Wasting | | | |
| |Syndrome | | | |
|90191-3 |WASTING SYNDROME INFORMATION, OCCURANCE INDICATOR |CE |1,1 |HL70136 |
| |This conveys whether the patient has a Wasting Syndrome in addition to| | | |
| |the GHD. | | | |
| | | | | |
| |N No | | | |
| |Y Yes | | | |
|90192-3 |WASTING SYNDROME INFORMATION, WEIGHT LOSS EQUAL TO OR GREATER THAN 10%|CE |0,1 |HL70136 |
| |This conveys whether the patient has experienced unintentional weight | | | |
| |loss equal to or greater than 10% of body mass. | | | |
| | | | | |
| |N No | | | |
| |Y Yes | | | |
|90193-3 |WASTING SYNDROME INFORMATION, DUE TO TREATABLE CONDITION INDICATOR |CE |0,1 |HL70136 |
| |This defines whether the Wasting Syndrome is due to a treatable | | | |
| |condition, e.g. an autoimmune disorder. | | | |
| | | | | |
| |N No | | | |
| |Y Yes | | | |
|90194-3 |WASTING SYNDROME INFORMATION, TREATABLE CONDITION STATUS INDICATOR |CE |0,1 |HL70136 |
| |This indicates whether the treatable condition that is precipitating | | | |
| |the Wasting Syndrome is being treated. Required if answer to Wasting | | | |
| |Syndrome Information, Due to Treatable Condition Indicator equals "Y" | | | |
| |Yes. | | | |
| | | | | |
| |N No | | | |
| |Y Yes | | | |
|90200-3 |NUTRITIONAL INFORMATION | |0,1 | |
| |The information in this section is used to convey whether the | | | |
| |nutritional intake, both quantity and variety, is a contributory | | | |
| |factor in the GHD. | | | |
|90201-3 |NUTRITIONAL INFORMATION, ASSESSMENT INDICATOR |CE |0,1 | HL79051 |
| |This conveys whether there has been an assessment of the patient's | | | |
| |diet and nutritional status. Information on nutritional assessment is | | | |
| |required if patient has Wasting Syndrome. | | | |
| | | | | |
| |CMP Completed | | | |
| |PLD Planned | | | |
|90202-3 |NUTRITIONAL INFORMATION, ASSESSMENT DATE |DT |1,1 | |
| |This is the date of scheduled or completed nutritional assessment. | | | |
|90203-3 |NUTRITIONAL INFORMATION, CONCURRENT THERAPY INDICATOR |CE |0,1 |HL70136 |
| |This is used to convey whether the patient is receiving nutritional | | | |
| |counseling and treatment. | | | |
| | | | | |
| |N No | | | |
| |Y Yes | | | |
|90210-3 |LABORATORY GH STIMULATION | |1,n | |
| |Provocative growth hormone stimulation, a minimum of 2 tests required.| | | |
|90211-3 |LABORATORY GH STIMULATION, AGENT NAME |TX |1,1 | |
| |This is the name of the stimulation agent used to induce GH release in| | | |
| |the GH stimulation test. | | | |
|90212-3 |LABORATORY GH STIMULATION, PEAK VALUES |NM |1,n |iso+ |
| |This reports the peak values of GH activity achieved with provocative | | |ans+ |
| |stimulation by named agent. | | | |
|90213-3 |LABORATORY GH STIMULATION, DATE |DT |1,1 | |
| |This is the date GH Stimulation testing was performed. | | | |
|90220-3 |PHYSICAL FINDINGS, PATIENT HEIGHT | |0,1 | |
| |This is used to report the height of the patient as measured at named | | | |
| |intervals. | | | |
|90221-3 |PHYSICAL FINDINGS, PATIENT HEIGHT AT BIRTH |NM |0,1 |iso+ |
| |This is the patient's height at birth or in the neonatal period. | | |ans+ |
| |Height will be reported in iso+ units of either cm (centimeters) or in| | | |
| |(inches). | | | |
|90222-3 |PHYSICAL FINDINGS, CURRENT PATIENT HEIGHT |NM |1,1 |iso+ |
| |This is the patient's height at the time of the request. | | |ans+ |
| | | | | |
| |Height will be reported in iso+ units of either cm (centimeters) or in| | | |
| |(inches). | | | |
|90223-3 |PHYSICAL FINDINGS, CURRENT PATIENT HEIGHT - DATE OF MEASUREMENT |DT |1,1 | |
| |This is the date that the current height measured | | | |
|90224-3 |PHYSICAL FINDINGS, BASELINE PATIENT HEIGHT |NM |1,1 |iso+ |
| |This is the baseline height measured at least six months prior to | | |ans+ |
| |request for GH therapy. It is used for assessing growth rate before | | | |
| |and after GH therapy | | | |
| | | | | |
| |Height will be reported in iso+ units of either cm (centimeters) or in| | | |
| |(inches). | | | |
|90225-3 |PHYSICAL FINDINGS, BASELINE PATIENT HEIGHT - DATE OF MEASUREMENT |DT |1,1 | |
| |This the date the baseline height was measured. | | | |
|90226-3 |PHYSICAL FINDINGS – PATIENT HEIGHT AT ONSET OF TREATMENT |NM |0,1 |iso+ |
| |This is the patient height as measured immediately prior to treatment | | |ans+ |
| |initiation. Required if Treatment has been initiated. | | | |
| | | | | |
| |Height will be reported in iso+ units of either cm (centimeters) or in| | | |
| |(inches). | | | |
|90227-3 |PHYSICAL FINDINGS – PATIENT HEIGHT AT ONSET OF TREATMENT – DATE OF |DT |0,1 | |
| |MEASUREMENT | | | |
| |This is the date of measurement at or immediately prior to onset of | | | |
| |treatment. Required if treatment has been initiated. | | | |
|90228-3 |PHYSICAL FINDINGS, PATIENT HEIGHT AT LAST RENEWAL |NM |0,1 |iso+ |
| |This is the patient height as measured when GH therapy last requested.| | |ans+ |
| | | | | |
| | | | | |
| |Height will be reported in iso+ units of either cm (centimeters) or in| | | |
| |(inches). | | | |
|90229-3 |PHYSICAL FINDINGS, PATIENT HEIGHT AT LAST RENEWAL, DATE OF |DT |0,1 | |
| |MEASUREMENT | | | |
| |This is the date the height was measured for the last request for | | | |
| |renewal. | | | |
|90230-3 |PHYSICAL FINDINGS, PATIENT WEIGHT | |0,1 | |
| |Weight of the patient at given intervals. | | | |
|90231-3 |PHYSICAL FINDINGS – PATIENT WEIGHT AT BIRTH |NM |0,1 |iso+ |
| |This is the weight of the patient at birth. | | |ans+ |
| | | | | |
| |Weight will be reported as either iso+ units of gm (grams) or kg | | | |
| |(kilograms) or ans+ units of oz (ounces) or lb (pounds). | | | |
|90232-3 |PHYSICAL FINDINGS, CURRENT PATIENT WEIGHT |NM |1,1 |iso+ |
| |This is the weight of the patient as of the time of this request. | | |ans+ |
| | | | | |
| |Weight will be reported as either iso+ units of gm (grams) or kg | | | |
| |(kilograms) or ans+ units of oz (ounces) or lb (pounds). | | | |
|90233-3 |PHYSICAL FINDINGS, CURRENT PATIENT WEIGHT - DATE OF MEASUREMENT |DT |1,1 | |
| |This is the date the current weight was measured. | | | |
|90234-3 |PHYSICAL FINDINGS, BASELINE PATIENT WEIGHT |NM |1,1 |iso+ |
| |Baseline weight, at least six months prior to request for GH therapy. | | |ans+ |
| | | | | |
| |Weight will be reported as either iso+ units of gm (grams) or kg | | | |
| |(kilograms) or ans+ units of oz (ounces) or lb (pounds). | | | |
|90235-3 |PHYSICAL FINDINGS, BASELINE PATIENT WEIGHT - DATE OF MEASUREMENT |DT |1,1 | |
| |This is the date baseline weight was measured | | | |
|90236-3 |PHYSICAL FINDINGS, PATIENT WEIGHT AT ONSET OF TREATMENT |NM |0,1 |iso+ |
| |This is the patient's weight as measured when treatment initiated. | | |ans+ |
| |Required if treatment has been initiated. | | | |
| | | | | |
| |Weight will be reported as either iso+ units of gm (grams) or kg | | | |
| |(kilograms) or ans+ units of oz (ounces) or lb (pounds). | | | |
|90237-3 |PHYSICAL FINDINGS, PATIENT WEIGHT AT ONSET OF TREATMENT - DATE OF |DT |0,1 | |
| |MEASUREMENT | | | |
| |This is the patient weight as measured at or immediately prior to the | | | |
| |onset of treatment. Required if treatment has been initiated. | | | |
|90238-3 |PHYSICAL FINDINGS, PATIENT WEIGHT AT LAST RENEWAL |NM |0,1 |iso+ |
| |This is the patient weight as measured when GH therapy was last | | |ans+ |
| |requested. | | | |
| | | | | |
| |Weight will be reported as either iso+ units of gm (grams) or kg | | | |
| |(kilograms) or ans+ units of oz (ounces) or lb (pounds). | | | |
|90239-3 |PHYSICAL FINDINGS, PATIENT WEIGHT LAST RENEWAL - DATE OF MEASUREMENT |DT |0,1 | |
| |This is the date the patient weight was measured for the last renewal | | | |
| |request. | | | |
|90240-3 |PATIENT BODY MASS INDEX | |0,1 | |
| |This is information regarding the patient's body mass index. | | | |
|90241-3 |PATIENT BODY MASS INDEX, CURRENT |NM |1,1 |iso+ |
| |This the patient's Body Mass Index (BMI) as calculated at the time of | | | |
| |the request | | | |
| | | | | |
| |Must be reported in iso+ units of IU (international units). | | | |
|90242-3 |PATIENT BODY MASS INDEX, AT ONSET OF TREATMENT |NM |0,1 |iso+ |
| |This is the Body Mass Index as calculated at the time of onset of GH | | | |
| |treatment. | | | |
| | | | | |
| |Must be reported in iso+ units of IU (international units). | | | |
|90250-3 |PARENTAL HEIGHT | |0,1 | |
| |Parental height information. May be required for coverage of | | | |
| |childhood GH therapy. | | | |
|90251-3 |PARENTAL HEIGHT, AVAILABILITY INDICATOR |CE |1,1 |HL79052 |
| |This reflects the availability of parental height information. | | | |
| | | | | |
| |MK Mother Known | | | |
| |FK Father Known | | | |
| |BK Both Known | | | |
| |BU Both Unknown | | | |
|90252-3 |PARENTAL HEIGHT, MOTHER |NM |0,1 |iso+ |
| |Mother's height if known. Required if the Parental Height, | | |ans+ |
| |Availability Indicator equals "MK" mother known or "BK" both known. | | | |
| | | | | |
| |Height will be reported in iso+ units of either cm (centimeters) or in| | | |
| |(inches). | | | |
|90253-3 |PARENTAL HEIGHT, FATHER |NM |0,1 |iso+ |
| |Father's height if known. Required if the Parental Height, | | |ans+ |
| |Availability Indicator equals "FK" father known or "BK" both known. | | | |
| | | | | |
| |Height will be reported in iso+ units of either cm (centimeters) or in| | | |
| |(inches). | | | |
|90080-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS | |0,n | |
| |Information about other drugs previously prescribed for treatment of | | | |
| |this condition with less than optimal outcomes. | | | |
|90081-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG NAME |TX |1,1 | |
| |This is the descriptive name of the drug previously used to treat the | | | |
| |diagnosis. | | | |
|90082-x |DRUG HISTORY - PRIOR THERAPY FOR DIAGNOSIS, - DRUG CODE |CE |1,1 |NDC |
| |The code assigned to the drug previously used to treat the diagnosis | | |RxNorm SCD |
| |as defined by: Representative NDC, RxNorm SCD or RxNorm SBD | | |RxNorm SBD |
|90083-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DURATION OF THERAPY |NM |1,1 |iso+ |
| |Duration of previous therapy in days. | | | |
|90084-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR THERAPY |CE |1,1 |HL79040 |
| |DISCONTINUED | | | |
| |This is the reason that prior drug therapy was discontinued. | | | |
| | | | | |
| |NTEFF Not or No Longer Effective | | | |
| |SDEFT Side Effects/Tolerance | | | |
| |NTCMP Not Compatible | | | |
| |OTH Other | | | |
|90085-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - NAME OF INCOMPATIBLE |TX |0,n | |
| |DRUG(S) | | | |
| |The descriptive name of the drug Incompatible with the prior therapy. | | | |
| |If Drug History, Prior Therapy for Diagnosis - Reason Prior Therapy | | | |
| |Discontinued equals "NTCMP" Not Compatible, then this is required. | | | |
|90086-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON(S) PRIOR THERAPY |TX |0,1 | |
| |DISCONTINUED, OTHER | | | |
| |Description of the other reason for discontinued therapy. If Drug | | | |
| |History, Prior Therapy for Diagnosis - Reason Prior Therapy | | | |
| |Discontinued equals "OTH" Other, then this is required. | | | |
|90090-x |CONCURRENT THERAPY | |0,n | |
| |Drugs the patient is currently on, for this or other diagnoses, which | | | |
| |might impact the requested drug. | | | |
|90091-x |CONCURRENT THERAPY, DRUG NAME |TX |0,1 | |
| |The descriptive name of the drug(s) used in concurrent therapy, for | | | |
| |this or other diagnoses, which may impact the requested drug. | | | |
|90092-x |CONCURRENT THERAPY, DRUG CODE |CE |1,1 |NDC |
| |The code assigned to the concurrent drug as defined by: | | |RxNorm SCD |
| |Representative NDC, RxNorm SCD, or RxNorm SBD | | |RxNorm SBD |
4 Proton Pump Inhibitors (PPI) Value Table
Table 3.4 Proton Pump Inhibitors Value Table
|LOINC code |Value |Data Type |Card |Response Code |
|Component Answer | | | |/ Numeric Units |
|90010-x |PRESCRIBER INFORMATION | |1,1 | |
| |Information about the practitioner prescribing the drug. | | | |
|90011-x |PRESCRIBER INFORMATION, NAME |PN |1,1 | |
| |This is the name of the practitioner prescribing the drug. | | | |
|90012-x |PRESCRIBER INFORMATION, IDENTIER |CX |1,n |NPI |
| |This may be repeated to convey multiple identifiers such as the DEA | | |DEA |
| |number, NPI, HCIdea Number or proprietary provider identifier. | | |HCIdea |
| | | | |Proprietary Provider |
| |Note: If the provider is a covered entity under HIPAA and the NPI is | | |ID |
| |mandated for use, the NPI must be sent as one of the identifiers and the | | | |
| |legacy provider identifier must not be used. | | |See note at left. |
|90013-x |PRESCRIBER INFORMATION, SPECIALITY TAXONOMY CODE |CE |1,1 |PTX |
| |This is the Taxonomy code that identifies the medical specialty of the | | | |
| |prescriber | | | |
|90020-x |PRESCRIBER CONTACT INFORMATION | |0,1 | |
| |Contact information for the individual prescribing the drug. | | | |
|90021-x |PRESCRIBER CONTACT INFORMATION, PHONE NUMBER |TX |1,1 | |
| |The phone number of the individual prescribing the drug. | | | |
|90022-x |PRESCRIBER CONTACT INFORMATION, FAX NUMBER |TX |0,1 | |
| |The fax number of the individual prescribing the drug. | | | |
|90030-x |DRUG PRESCRIBED | |1,1 | |
| |This is information about the drug requested in the prior authorization. | | | |
|90031-x |DRUG PRESCRIBED, NAME |TX |1,1 | |
| |This is the descriptive name of the drug prescribed. | | | |
|90032-x |DRUG PRESCRIBED, DRUG CODE |CE |1,1 |NDC |
| |This is the code identifier for the drug prescribed as defined by: | | |RxNorm SCD |
| |Representative NDC, RxNorm SCD or RxNorm SBD | | |RxNorm SBD |
| |. | | | |
|90033-x |DRUG PRESCRIBED, THERAPY TYPE |CE |1,1 |HL79038 |
| |This is used to convey the historical use of the prescribed drug as part | | | |
| |of the patient's therapy. | | | |
| | | | | |
| |INTRQ Initial Therapy | | | |
| |CNTRQ Continued Therapy | | | |
| |RPLRQ Replacement Therapy | | | |
| |ADDRQ Add on Therapy | | | |
|90034-x |DRUG PRESCRIBED, SELF ADMINISTERED INDICATOR |CE |0,1 |HL70136 |
| | | | | |
| |N No | | | |
| |Y Yes | | | |
|90260-4 |PPI, RELATED DIAGNOSIS | |1,1 | |
| |This is the related diagnosis of the patient for which the drug is a | | | |
| |prescribed therapy. | | | |
| | | | | |
| |Note: Prior to U.S. adoption of ICD-10-CM, use ICD-9-CM in the U.S. | | | |
| |domain. After adoption as the standard for defining diagnoses in the US,| | | |
| |use only ICD-10-CM for requests in the US. | | | |
|90260-4 | |CE |1,1 |IC9 |
| | | | |IC10 |
|90270-4 |DIAGNOSIS CONFIRMATION AND LEVEL OF TREATMENT NEEDED | |1,1 | |
| |Diagnosis procedures and criteria confirming the diagnosis and level of | | | |
| |treatment needed. | | | |
| |DIAGNOSIS CONFIRMATION AND LEVEL OF TREATMENT NEEDED, PROCEDURE EMPLOYED |CE |1,n |HL79053 |
|90271-4 |These are procedures performed to establish the diagnosis. | | | |
| | | | | |
| |BMS Barium Studies | | | |
| |EGD Endoscopy | | | |
| |BIO Biopsy | | | |
|90272-4 |DIAGNOSIS CONFIRMATION AND LEVEL OF TREATMENT NEEDED, GERD BY ENDOSCOPY |CE |0,1 |HL79054 |
| |TYPE | | | |
| |This is the level of severity of GERD as confirmed by endoscopy. Required| | | |
| |when GERD confirmed by endoscopy. | | | |
| | | | | |
| |See section 5 for the list of valid codes. | | | |
|90280-4 |PPI, PATIENT HISTORY - STRICTURE PRESENT | |0,1 | |
| |This conveys information that esophageal stricture is present with the | | | |
| |related diagnosis. Required if the related diagnosis is "Barrett | | | |
| |Esophagus". | | | |
|90280-4 | |CE |1,1 |HL70136 |
| |N No | | | |
| |Y Yes | | | |
|90080-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS | |0,n | |
| |Information about other drugs previously prescribed for treatment of this| | | |
| |condition with less than optimal outcomes. | | | |
|90081-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG NAME |TX |1,1 | |
| |This is the descriptive name of the drug previously used to treat the | | | |
| |diagnosis. | | | |
|90082-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG CODE |CE |1,1 |NDC |
| |The code assigned to the drug previously used to treat the diagnosis as | | |RxNorm SCD |
| |defined by: Representative NDC, RxNorm SCD or RxNorm SBD | | |RxNorm SBD |
|90083-x |DRUG HISTORY,PRIOR THERAPY FOR DIAGNOSIS - DURATION OF THERAPY |NM |1,1 |iso+ |
| |Duration of previous therapy in days. | | | |
|90084-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR THERAPY |CE |1,1 |HL79040 |
| |DISCONTINUED | | | |
| |This is the reason that the prior drug therapy was discontinued. | | | |
| | | | | |
| |NTEFF Not or No Longer Effective | | | |
| |SDEFT Side Effects/Tolerance | | | |
| |NTCMP Not Compatible | | | |
| |OTH Other | | | |
|90085-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS, REASON(S) PRIOR THERAPY |TX |0,1 | |
| |DISCONTINUED, OTHER | | | |
| |Description of the other reason for discontinued therapy. If Drug | | | |
| |History, Prior Therapy for Diagnosis - Reason Prior Therapy Discontinued | | | |
| |equals "OTH" Other, then this is required. | | | |
|90086-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - INCOMPATIBLE DRUG NAME |TX |0,n | |
| |The descriptive name of the drug incompatible with the prior therapy. If | | | |
| |Drug History, Prior Therapy for Diagnosis – Reason Therapy Discontinued | | | |
| |equals "NTCMP" Not Compatible, then this is required. | | | |
|90090-x |CONCURRENT THERAPY | |0,n | |
| |Drugs the patient is currently on, for this or other diagnoses, which | | | |
| |might impact the requested drug. | | | |
|90091-x |CONCURRENT THERAPY, DRUG NAME |TX |0,1 | |
| |The descriptive name of the drug(s) used in concurrent therapy, for this | | | |
| |or other diagnoses, which may impact the requested drug. | | | |
|90092-x |CONCURRENT THERAPY, DRUG CODE |CE |1,1 |NDC |
| |The code assigned to the ordered drug as defined by: Representative NDC,| | |RxNorm SCD |
| |RxNorm SCD, or RxNorm SBD | | |RxNorm SBD |
|90110-x |NSAIDS/PPI RELATED CONCURRENT THERAPY | |0,1 | |
| |NSAID/PPI related drugs being used concurrently with the requested drug. | | | |
|90111-x |NSAIDS/PPI RELATEDE, CONCURRENT THERAPY, TYPE |CE |1,1 |HL79041 |
| |Concurrent NSAIDS/PPI related drug therapies being used for treatment of | | | |
| |this or other conditions. | | | |
| | | | | |
| |See section 5 for the list of valid codes. | | | |
|90112-x |NSAIDS/PPI RELATED CONCURRENT THERAPY, OTHER TYPE |TX |0,1 | |
| |The descriptive name of the NSAIDS/PPI related drug(s) used in concurrent| | | |
| |therapy. Required when NSAIDS/PPI Related Concurrent Therapy, Type | | | |
| |equals “OTH” Other. | | | |
|90290-4 |H-PYLORI INFORMATION | |0,1 | |
| |H-Pylori status in relation to the need for PPI. | | | |
|90291-4 |H-PYLORI INFORMATION, STATUS |CE |1,1 |HL79056 |
| |This is the documented H-Pylori status of the patient. | | | |
| | | | | |
| |PS Positive | | | |
| |NE Negative | | | |
|90292-4 |H-PYLORI INFORMATION, CONFIRMED BY |CE |1,n |HL79057 |
| |This conveys the method used to confirm H-Pylori. | | | |
| | | | | |
| |See section 5 for the list of valid codes. | | | |
|90293-4 |H-PYLORI INFORMATION, CONFIRMED BY - OTHER |TX |0,1 | |
| |Description of the method used to confirm the presence of H-Pylori, | | | |
| |required when the response to H-Pylori Information, Confirmed by equals | | | |
| |"OTH" Other. | | | |
|90300-4 |H-PYLORI TREATMENT | |0,1 | |
| |H-Pylori treated or being treated. | | | |
|90301-4 |H-PYLORI TREATMENT, CDA PROTOCOL INDICATOR |CE |1,1 |HL70136 |
| |This conveys whether the treatment of H-Pylori is/was/will be done in | | | |
| |compliance with CDA protocols. | | | |
| | | | | |
| |N No | | | |
| |Y Yes | | | |
|90302-4 |H-PYLORI TREATMENT, START DATE |DT |0,1 | |
| |This is the date that treatment of H-Pylori began or is to begin. | | | |
|90303-4 |H-PYLORI TREATMENT, END DATE |DT |0,1 | |
| |Date treatment of H-Pylori was or is expected to be completed. | | | |
5 Erectile Dysfunction (ED) Agents Value Table
Table 3.5 Erectile Dysfunction Agents Value Table
|LOINC code |Value |Data Type |Card |Response Code |
|Component Answer | | | |/ Numeric Units |
|90010-x |PRESCRIBER INFORMATION | |1,1 | |
| |Information about the practitioner prescribing the drug. | | | |
|90011-x |PRESCRIBER INFORMATION, NAME |PN |1,1 | |
| |This is the name of the practitioner prescribing the drug. | | | |
|90012-x |PRESCRIBER INFORMATION, IDENTIER |CX |1,n |NPI |
| |This may be repeated to convey multiple identifiers such as the DEA | | |DEA |
| |number, NPI, HCIdea Number or proprietary provider identifier. | | |HCIdea |
| | | | |Proprietary |
| |Note: If the provider is a covered entity under HIPAA and the NPI is | | |Provider ID |
| |mandated for use, the NPI must be sent as one of the identifiers and the | | | |
| |legacy provider identifier must not be used. | | |See note at left. |
|90013-x |PRESCRIBER INFORMATION, SPECIALITY TAXONOMY CODE |CE |1,1 |PTX |
| |This is the Taxonomy code that identifies the medical specialty of the | | | |
| |prescriber. | | | |
|90020-x |PRESCRIBER CONTACT INFORMATION | |0,1 | |
| |Contact information for the individual prescribing the drug. | | | |
|90021-x |PRESCRIBER CONTACT INFORMATION, PHONE NUMBER |TX |1,1 | |
| |The phone number of the individual prescribing the drug. | | | |
|90022-x |PRESCRIBER CONTACT INFORMATION, FAX NUMBER |TX |0,1 | |
| |The fax number of the individual prescribing the drug. | | | |
|90030-x |DRUG PRESCRIBED | |1,1 | |
| |This is information about the drug requested in the prior authorization. | | | |
|90031-x |DRUG PRESCRIBED, NAME |TX |1,1 | |
| |This is the descriptive name of the drug prescribed. | | | |
|90032-x |DRUG PRESCRIBED, DRUG CODE |CE |1,1 |NDC |
| |This is the code identifier for the drug prescribed as defined by: | | |RxNorm SCD |
| |Representative NDC, RxNorm SCD or RxNorm SBD | | |RxNorm SBD |
|90033-x |DRUG PRESCRIBED, THERAPY TYPE |CE |1,1 |HL79038 |
| |This is used to convey the historical use of the prescribed drug as part | | | |
| |of the patient's therapy. | | | |
| | | | | |
| |INTRQ Initial Therapy | | | |
| |CNTRQ Continued Therapy | | | |
| |RPLRQ Replacement Therapy | | | |
| |ADDRQ Add on Therapy | | | |
|90034-x |DRUG PRESCRIBED, SELF ADMINISTERED INDICATOR | |0,1 |HL70136 |
| |This indicator defines if the drug can be self administered. | | | |
| | | | | |
| |N No | | | |
| |Y Yes | | | |
|90310-5 |ERECTILE DYSFUNCTION, RELATED DIAGNOSIS | |1,1 | |
| |This is the related diagnosis of the patient for which the drug is a | | | |
| |prescribed therapy. | | | |
| | | | | |
| |Note: Prior to U.S. adoption of ICD-10-CM, use ICD-9-CM in the U.S. | | | |
| |domain. After adoption as the standard for defining diagnoses in the US,| | | |
| |use only ICD-10-CM for requests in the US. | | | |
|90310-5 | |CE |1,1 |IC9 |
| | | | |IC10 |
|90320-5 |ED, RELATED DIAGNOSIS CONFIRMATION INFORMATION | |1,n | |
| |This is information about how the diagnosis was confirmed. | | | |
|90321-5 |ED, RELATED DIAGNOSIS CONFIRMATION – CONFIRMED BY |CE |1,n |HL79057 |
| |This reports tests used to confirm the ED diagnosis | | | |
| | | | | |
| |See section 5 for the list of valid codes. | | | |
|90322-5 |ED, RELATED DIAGNOSIS CONFIRMATION – ED DIAGNOSIS CONFIRMED BY, OTHER |TX |0,1 | |
| |This is used to convey the name of the other test used to confirm ED. It | | | |
| |is required when Erectile Dysfunction, Patient History – ED Diagnosis | | | |
| |Confirmed By equals "OTH" Other. | | | |
|90323-5 |ED, RELATED DIAGNOSIS CONFIRMATION – RESULT |NM |1,1 |iso+ |
| |This is the result of the test confirming diagnosis of ED | | | |
|90324-5 |ED, RELATED DIAGNOSIS CONFIRMATION - DATE |DT |1,1 | |
| |This is the date that the test confirming diagnosis of ED was performed. | | | |
|90330-5 |ED, PATIENT HISTORY INFORMATION | |1,1 | |
| |This is information relating to the history of the patient. | | | |
|90331-5 |ED, PATIENT HISTORY – PULMONARY HYPERTENSION FUNCTIONAL LEVEL |CE |0,1 |HL79058 |
| |Functional Level of Individual with Primary Pulmonary Hypertension, | | | |
| |Peripheral Artery Hypertension or Pulmonary Artery Hypertension | | | |
| | | | | |
| |C1 Class I | | | |
| |C2 Class II | | | |
| |C3 Class III | | | |
| |C4 Class IV | | | |
|90332-5 |ED, PATIENT HISTORY – EVALUATION TYPE COMPLETED |CE |1,1 |HL79059 |
| |This conveys whether the patient has been evaluated for general health or| | | |
| |contributory factors. | | | |
| | | | | |
| |GH General Health Status Evaluation | | | |
| |UC Investigation of Underlying Causes of Primary Condition | | | |
| |NA Not applicable | | | |
|90333-5 |ED, PATIENT HISTORY – ED LEVEL INDICATOR |CE |1,1 |HL70136 |
| |This indicator defines whether the dysfunction is present 50% or more of | | | |
| |the time in the last 6 months. | | | |
| | | | | |
| |Y Yes | | | |
| |N No | | | |
|90334-5 |ED, PATIENT HISTORY – ED RELATED TO |CE |0,n |HL79060 |
| |This is used to convey information related to other conditions resulting | | | |
| |in ED | | | |
| | | | | |
| |See section 5 for the list of valid codes. | | | |
|90340-5 |ED, TREATMENT OF RELATED CAUSES | |0,1 | |
| |Treatment status of conditions precipitating ED. | | | |
|90341-5 |ED, TREATMENT OF RELATED CAUSES – TREATMENT OF REVERSIBLE CAUSES STATUS |CE |1,1 |HL79048 |
| |Treatment status of conditions precipitating ED. | | | |
| | | | | |
| |See section 5 for the list of valid codes. | | | |
|90342-5 |ED, TREATMENT OF RELATED CAUSES – RADIATION THERAPY STATUS |CE |0,1 |HL79048 |
| |This is used to convey the status of Radiation Therapy, It is required if| | | |
| |the related diagnosis is Testicular Cancer. | | | |
| | | | | |
| |See section 5 for the list of valid codes. | | | |
|90343-5 |ED, TREATMENT OF RELATED CAUSES – RADIATION THERAPY START DATE |DT |0,1 | |
| |This is the date that radiation therapy began. It is required if | | | |
| |radiation therapy is planned or in progress. | | | |
|90344-5 |ERECTILE DYSFUNCTION, TREATMENT OF RELATED CAUSES – RADIATION THERAPY END|DT |0,1 | |
| |DATE | | | |
| |This is the date that radiation therapy was or is expected to be | | | |
| |completed. Required when Radiation Therapy employed for treatment. | | | |
|90345-5 |ED, TREATMENT OF RELATED CAUSES – SURGICAL TREATMENT INDICATOR |CE |0,1 |HL79051 |
| |This conveys information about whether the related condition can or has | | | |
| |been treated with surgery. It is required if the related diagnosis is | | | |
| |Testicular Cancer. | | | |
| | | | | |
| |CMP Completed | | | |
| |PLD Planned | | | |
|90346-5 |ED, TREATMENT OF RELATED CAUSES – SURGERY DATE |DT |0,1 | |
| |This is the date that surgery was or is expected to be accomplished. | | | |
| |Required when Surgery is employed for treatment of Testicular Cancer. | | | |
|90347-5 |ED, TREATMENT OF RELATED CAUSES – PSYCHOGENIC CAUSES OF ED TREATMENT |CE |0,1 |HL79061 |
| |This conveys information about whether the psychogenic components of ED | | | |
| |can or have been treated and if so, by what method. | | | |
| | | | | |
| |PSY Psychotherapy | | | |
| |BHT Behavior Therapy | | | |
| |OTT Other Therapy | | | |
| |NOT No Therapy | | | |
|90348-5 |ED, TREATMENT OF RELATED CAUSES – ED DRUG INDUCED INDICATOR |CE |0,1 |HL70136 |
| |This is used to convey whether the ED is secondary to drugs being taken | | | |
| |by the patient. | | | |
| | | | | |
| |N No | | | |
| |Y Yes | | | |
|90349-5 |ED, TREATMENT OF RELATED CAUSES – DRUG INDUCED OPTION |CE |0,1 |HL79062 |
| |This is used to define the options, if any, for altering the use of drug | | | |
| |that is precipitating ED. | | | |
| | | | | |
| |RDU Reduction in Drug Use | | | |
| |DCT Discontinue Drug Use | | | |
| |CGD Change Drug | | | |
| |DCN Drug Cannot be Changed or Discontinued | | | |
|90080-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS | |0,n | |
| |Information about other drugs previously prescribed for treatment of this| | | |
| |condition with less than optimal outcomes. | | | |
|90081-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG NAME |TX |1,1 | |
| |This is the descriptive name of the drug previously used to treat the | | | |
| |diagnosis. | | | |
|90082-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG CODE |CE |1,1 |NDC |
| |The code assigned to the drug previously used to treat the diagnosis as | | |RxNorm SCD |
| |defined by: Representative NDC, RxNorm SCD, or RxNorm SBD | | |RxNorm SBD |
|90083-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS, - DURATION OF THERAPY |NM |1,1 |iso+ |
| |Duration of previous therapy in days. | | | |
|90084-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR THERAPY |CE |1,1 |HL79040 |
| |DISCONTINUED | | | |
| |Reason prior drug therapy was discontinued. | | | |
| | | | | |
| |NTEFF Not or No Longer Effective | | | |
| |SDEFT Side Effects/Tolerance | | | |
| |NTCMP Not Compatible | | | |
| |OTH Other | | | |
|90085-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR THERAPY |TX |0,1 | |
| |DISCONTINUED, OTHER | | | |
| |Description of the other reason for discontinued therapy. If Drug | | | |
| |History, Prior Therapy for Diagnosis - Reason Prior Therapy Discontinued | | | |
| |equals "OTH" Other, then this is required. | | | |
|90086-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS – Reason Prior Therapy |TX |0,1 | |
| |Discontinued, NAME OF INCOMPATIBLE DRUG(S) | | | |
| |The descriptive name of the drug incompatible with the prior therapy. If | | | |
| |Drug History, Prior Therapy for Diagnosis - Reason Prior Therapy | | | |
| |Discontinued equals "NTCMP" Not Compatible, then this is required. | | | |
|90090-x |CONCURRENT THERAPY | |0,n | |
| |Drugs the patient is currently on, for this or other diagnoses, which | | | |
| |might impact the requested drug. | | | |
|90091-x |CONCURRENT THERAPY, DRUG NAME |TX |0,1 | |
| |The descriptive name of the drug(s) used in concurrent therapy, for this | | | |
| |or other diagnoses, which may impact the requested drug. | | | |
|90092-x |CONCURRENT THERAPY, DRUG CODE |CE |1,1 |NDC |
| |The code assigned to the concurrnt drug as defined by: Representative | | |RxNorm SCD |
| |NDC, RxNorm SCD, or RxNorm SBD | | |RxNorm SBD |
|90350-5 |ED RELATED CONCURRENT THERAPY | |0,1 | |
| |ED related drugs being used concurrently with the requested drug. | | | |
|90351-5 |ED RELATED CONCURRENT THERAPY, TYPE |CE |1,1 |HL79063 |
| |Concurrent ED related drug therapies being used for treatment of this or | | | |
| |other conditions. | | | |
| | | | | |
| |See section 5 for the list of valid codes. | | | |
|90352-5 |ED RELATED CONCURRENT THERAPY, DRUG NAME(S) |TX |0,1 | |
| |The descriptive name of the ED related drug(s) used in concurrent | | | |
| |therapy. Required when ED Related Concurrent Therapy, Type equals “OTH” | | | |
| |Other. | | | |
6 Narcotic(Opioid) Agonists Value Table
Table 3.6 Narcotic(Opioid) Agonists Value Table
|LOINC code |Value |Data Type |Card |Response Code |
|Component Answer | | | |/ Numeric Units |
|90010-x |PRESCRIBER INFORMATION | |1,1 | |
| |Information about the practitioner prescribing the drug. | | | |
|90011-x |PRESCRIBER INFORMATION, NAME |PN |1,1 | |
| |This is the name of the practitioner prescribing the drug. | | | |
|90012-x |PRESCRIBER INFORMATION, IDENTIER |CX |1,n |NPI |
| |This may be repeated to convey multiple identifiers such as the DEA | | |DEA |
| |number, NPI, HCIdea Number or proprietary provider identifier. | | |HCIdea |
| | | | |Proprietary Provider|
| |Note: If the provider is a covered entity under HIPAA and the NPI is | | |ID |
| |mandated for use, the NPI must be sent as one of the identifiers and | | | |
| |the legacy provider identifier must not be used. | | |See note at left. |
|90013-x |PRESCRIBER INFORMATION, SPECIALITY TAXONOMY CODE |CE |1,1 |PTX |
| |Taxonomy code that identifies the medical specialty of the prescriber | | | |
|90020-x |PRESCRIBER CONTACT INFORMATION | |0,1 | |
| |Contact information for the individual prescribing the drug. | | | |
|90021-x |PRESCRIBER CONTACT INFORMATION, PHONE NUMBER |TX |1,1 | |
| |The phone number of the individual prescribing the drug. | | | |
|90022-x |PRESCRIBER CONTACT INFORMATION, FAX NUMBER |TX |0,1 | |
| |The fax number of the individual prescribing the drug. | | | |
|90030-x |DRUG PRESCRIBED | |1,1 | |
| |This is information about the drug requested in the prior | | | |
| |authorization. | | | |
|90031-x |DRUG PRESCRIBED, NAME |TX |1,1 | |
| |This is the descriptive name of the drug prescribed. | | | |
|90032-x |DRUG PRESCRIBED, DRUG CODE |CE |1,1 |NDC |
| |This is the code identifier for the drug prescribed as defined by: | | |RxNorm SCD |
| |Representative NDC, RxNorm SCD or RxNorm SBD. | | |RxNorm SBD |
|90033-x |DRUG PRESCRIBED, THERAPY TYPE |CE |1,1 |HL79038 |
| |This is used to convey the historical use of the prescribed drug as | | | |
| |part of the patient’s therapy. | | | |
| | | | | |
| |INTRQ Initial Therapy | | | |
| |CNTRQ Continued Therapy | | | |
| |RPLRQ Replacement Therapy | | | |
| |ADDRQ Add on Therapy | | | |
|90034-x |DRUG PRESCRIBED, SELF ADMINISTERED INDICATOR |CE |0,1 |HL70136 |
| |This indicator defines if the drug can be self administered. | | | |
| | | | | |
| |N No | | | |
| |Y Yes | | | |
|90360-6 |NARCOTIC (OPIOID) AGONISTS, RELATED DIAGNOSIS | |1,1 | |
| |This is the related diagnosis of the patient for which the drug is a | | | |
| |prescribed therapy. | | | |
| | | | | |
| |Note: Prior to U.S. adoption of ICD-10-CM, use ICD-9-CM in the U.S. | | | |
| |domain. After adoption as the standard for defining diagnoses in the | | | |
| |US, use only ICD-10-CM for requests in the US. | | | |
|90360-6 | |CE |1,1 |IC9 |
| | | | |IC10 |
|90370-6 |NARCOTIC (OPIOID) AGONISTS, PATIENT HISTORY | |1,1 | |
| |Patient history related to the prescribed drug. | | | |
|90371-6 |NARCOTIC (OPIOID) AGONISTS, PATIENT HISTORY – PAIN SYNDROME SOURCE |CE |1,1 |HL79064 |
| |This conveys information regarding the source or type of pain the | | | |
| |patient is experiencing. | | | |
| | | | | |
| |See section 5 for the list of valid codes. | | | |
|90372-6 |NARCOTIC (OPIOID) AGONISTS, PATIENT HISTORY – PAIN SYNDROME SOURCE, |TX |0,1 | |
| |OTHER | | | |
| |Description of the source of the Pain Syndrome. Required when the | | | |
| |answer to Opioid Agonists, Patient History – Pain Syndrome Source | | | |
| |equals “OTH”, other. | | | |
| |NARCOTIC (OPIOID) AGONISTS, PATIENT HISTORY – PAIN SYNDROME FRENQUENCY|CE |1,1 |HL79065 |
|90373-6 |Frequency with which pain occurs. | | | |
| | | | | |
| |CP Constant Pain | | | |
| |ITP Intermittent Pain | | | |
| |ICP Incidental Pain | | | |
| |NARCOTIC (OPIOID) AGONISTS, PATIENT HISTORY – PAIN SYNDROME |CE |1,1 |HL79066 |
|90374-6 |Persistence | | | |
| |Anticipated duration/persistence of pain. | | | |
| | | | | |
| |AL Acute Limited – less than 30 Days | | | |
| |CR Chronic | | | |
| |CRP Chronic Progressive | | | |
| |CPR Chronic Progressive with Escalating Opioid | | | |
|90380-6 |NARCOTIC (OPIOID) AGONISTS, COMPLICATING CONDITION INFORMATION | |1,n | |
| |Information about co-morbid conditions complicating or exacerbating | | | |
| |pain management. | | | |
| |NARCOTIC (OPIOID) AGONISTS, COMPLICATING CONDITIONS |CE |1,1 |HL79067 |
|90381-6 |Co-morbid conditions complicating or exacerbating pain management. | | | |
| | | | | |
| |See section 5 for the list of valid codes. | | | |
| |NARCOTIC (OPIOID) AGONISTS, COMPLICATING CONDITIONS, OTHER |TX |0,1 | |
|90382-6 |Description of co-morbid condition. Required when answer to | | | |
| |Complicating Condition equals “OTH” Other. | | | |
|90390-6 |Narcotic (Opioid) Agonists, Laboratory information | |1,n | |
| |Report of drug screens performed since last review or escalation of | | | |
| |drug therapy. | | | |
| |Narcotic (Opioid) Agonists, Laboratory – Name of Test |TX |1,1 | |
|90391-6 |The name of the test used to verify the presence of the Opioid. | | | |
| |Narcotic (Opioid) Agonists, Laboratory - Date of Test |DT |1,1 | |
|90392-6 |Date test performed | | | |
| |Narcotic (Opioid) Agonists, Laboratory – TEST Result |NM |1,1 |iso+ |
|90393-6 |This conveys the results of the drug screen. | | | |
|90080-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS | |0,n | |
| |Information about other drugs previously prescribed for pain | | | |
| |management, both opioid and non-opioid, with less than optimal | | | |
| |outcomes. | | | |
|90081-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS – DRUG NAME |TX |1,1 | |
| |Name of drug previously used for pain management. | | | |
|90082-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS – DRUG CODE |CE |1,1 |NDC |
| |The code assigned to the drug previously used to treat the diagnosis | | |RxNorm SCD |
| |as defined by: Representative NDC, RxNorm SCD or RxNorm SBD | | |RxNorm SBD |
|90083-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DURATION OF THERAPY |NM |1,1 |iso+ |
| |Duration of previous therapy in days. | | | |
|90084-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS – REASON PRIOR THERAPY |CE |1,1 |HL9040 |
| |DISCONTINUED | | | |
| |This is the reason that the prior pain therapy was discontinued. | | | |
| | | | | |
| |NTEFF Not or No Longer Effective | | | |
| |SDEFT Side Effects/Tolerance | | | |
| |NTCMP Not Compatible | | | |
| |OTH Other | | | |
|90085-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR THERAPY |TX |0,1 | |
| |DISCONTINUED, OTHER | | | |
| |Description of the other reason for discontinued therapy. If Drug | | | |
| |History, Prior Therapy for Pain Management – Reason Prior Therapy | | | |
| |Discontinued equals “OTH” Other, then this is required. | | | |
|90086-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS – INCOMPATIBLE DRUG NAME |TX |0,1 | |
| |The descriptive name of the drug Incompatible with the prior therapy. | | | |
| |If Drug History, Prior Therapy for Diagnosis – Reason Prior Therapy | | | |
| |Discontinued equals “NTCMP” Not Compatible, then this is required. | | | |
|90090-x |CONCURRENT THERAPY | |0,1 | |
| |Drugs the patient is currently on, for this or other diagnoses, which | | | |
| |might impact the requested drug. | | | |
|90091-x |CONCURRENT THERAPY, DRUG NAME |TX |0,1 | |
| |The descriptive name of the drug(s) used in concurrent therapy, for | | | |
| |this or other diagnoses, which may impact the requested drug. | | | |
|90092-x |CONCURRENT THERAPY – DRUG CODE |CE |1,1 |NDC |
| |The code assigned to the concurrent drug as defined by: | | |RxNorm SCD |
| |Representative NDC, RxNorm SCD, or RxNorm SBD | | |RxNorm SBD |
|90400-6 |OPIOID RELATED CONCURRENT PAIN THERAPY | |0,1 | |
| |Concurrent drug therapies used in pain management. | | | |
|90401-6 |OPIOID RELATED CONCURRENT PAIN THERAPY, NAME |TX |0,1 | |
| |Descriptive name of the Opioid and non-Opioid drugs used concurrently | | | |
| |for pain management. | | | |
|90402-6 |OPIOID RELATED CONCURRENT PAIN THERAPY, DRUG CODE |CE |1,1 |NDC |
| |The code assigned to the concurrent drug as defined by: | | |RxNorm SCD |
| |Representative NDC, RxNorm SCD, or RxNorm SBD. | | |RxNorm SBD |
|90403-6 |OPIOID RELATED CONCURRENT PAIN THERAPY, OPIOID LEVEL |CE |0,1 |HL79068 |
| |Level of concurrent Opioid therapy. | | | |
| | | | | |
| |RDL Recommended Dose Level | | | |
| |HPL High Potency Dose Level | | | |
| |24L 24 Hour High Potency Dose Level | | | |
| |OTL Opioid Tolerant | | | |
|90410-6 |Narcotic (Opioid) Agonist, Use for Treatment of Opioid Addiction | |0,1 | |
| |Use of Narcotic (Opioid) Agonists for the treatment of opioid | | | |
| |addiction. | | | |
|90411-6 |Narcotic (Opioid) Agonist, Use for Treatment of Opioid Addiction - |CE |1,1 |HL70136 |
| |Opioid Discontinued | | | |
| |This conveys whether the addicted drug has been discontinued. | | | |
| | | | | |
| |N No | | | |
| |Y Yes | | | |
|90412-6 |Narcotic (Opioid) Agonist, Use for Treatment of Opioid Addiction - |DT |1,1 | |
| |Date Opioid Discontinued | | | |
| |Date that the object drug of the addiction was discontinued or is | | | |
| |planned to be discontinued | | | |
|90413-6 |Narcotic (Opioid) Agonist, Use for Treatment of Opioid Addiction - |DT |1,1 | |
| |Induction TherAPy Date Initiated | | | |
| |Date induction therapy initiated or to be initiated. | | | |
|90414-6 |Narcotic (Opioid) Agonist Use for Treatment of Opioid Addiction, |DT |0,1 | |
| |Induction Therapy – Date Oral Initiated | | | |
| |Date to switch to oral medication if induction therapy initiated with | | | |
| |injectable drug. | | | |
|90415-6 |Narcotic (Opioid) Agonist Use for Treatment of Opioid Addiction - |NM |1,1 |iso+ |
| |Duration | | | |
| |Planned length of time on agonist treatment. | | | |
|90416-6 |Narcotic (Opioid) Agonist, Use for Treatment of Opioid Addiction - |TX |1,1 | |
| |dose Titration | | | |
| |Description of the titration plan or the agonist including time line. | | | |
7 Imidazole - Related Antifungals Value Table
Table 3.7 Imidazole - Related Antifungals Value Table
|LOINC code |Value |Data Type |Card |Response Code |
|Component Answer | | | |/ Numeric Units |
|90010-x |PRESCRIBER INFORMATION | |1,1 | |
| |Information about the practitioner prescribing the drug. | | | |
|90011-x |PRESCRIBER INFORMATION, NAME |PN |1,1 | |
| |This is the name of the practitioner prescribing the drug. | | | |
|90012-x |PRESCRIBER INFORMATION, IDENTIER |CX |1,n |NPI |
| |This may be repeated to convey multiple identifications such as the | | |DEA |
| |National Provider Identifier [NPI], the Drug Enforcement Act [DEA] | | |HCIdea |
| |number, Special DEA number, HCIdea number or proprietary identifier. | | |Proprietary |
| | | | |Provider ID |
| |Note: If the provider is a covered entity under HIPAA and the NPI is | | | |
| |mandated for use, the NPI must be sent as one of the identifiers and | | |See note at left. |
| |the legacy provider identifier must not be used. | | | |
|90013-x |PRESCRIBER INFORMATION, SPECIALTY TAXONOMY CODE |CE |1,1 |PTX |
| |Taxonomy code that identifies the medical specialty of the prescriber | | | |
|90020-x |PRESCRIBER CONTACT INFORMATION | |0,1 | |
| |Contact information for the individual prescribing the drug. | | | |
|90021-x |PRESCRIBER CONTACT INFORMATION, PHONE NUMBER |TX |1,1 | |
| |The phone number of the individual prescribing the drug. | | | |
|90022-x |PRESCRIBER CONTACT INFORMATION, FAX NUMBER |TX |0,1 | |
| |The fax number of the individual prescribing the drug. | | | |
|90030-x |DRUG PRESCRIBED | |1,1 | |
| |This is information about the drug requested in the prior | | | |
| |authorization. | | | |
|90031-x |DRUG PRESCRIBED, NAME |TX |1,1 | |
| |This is the descriptive name of the drug prescribed. | | | |
|90032-x |DRUG PRESCRIBED, DRUG CODE |CE |1,1 |NDC |
| |This is the code identifier for the drug prescribed as defined by: | | |RxNorm SCD |
| |Representative NDC, RxNorm SCD or RxNorm SBD | | |RxNorm SBD |
|90033-x |DRUG PRESCRIBED, THERAPY TYPE |CE |1,1 |HL79038 |
| |This is used to convey the historical use of the prescribed drug as | | | |
| |part of the patient's therapy. | | | |
| | | | | |
| |INTRQ Initial Therapy | | | |
| |CNTRQ Continued Therapy | | | |
| |RPLRQ Replacement Therapy | | | |
| |ADDRQ Add on Therapy | | | |
|90034-x |DRUG PRESCRIBED, SELF ADMINISTERED INDICATOR |CE |0,1 |HL70136 |
| |This indicator defines if the drug can be self administered. | | | |
| | | | | |
| |N No | | | |
| |Y Yes | | | |
|90420-7 |Drug Prescribed, TOPICAL THERAPY | |0,1 | |
| |Information about why a topical therapy was prescribed. | | | |
|90421-7 |Drug Prescribed, TOPICAL THERAPY - REASON |CE |1,1 |HL79069 |
| |The reason a topical therapy was prescribed. | | | |
| | | | | |
| |UTS Unable to swallow | | | |
| |HDS Hepatic Dysfunction | | | |
| |OTH Other (If used, then Topical Therapy Reason – Other must be | | | |
| |completed) | | | |
|90422-7 |Drug Prescribed, TOPICAL THERAPY- REASON, OTHER |TX |0,1 | |
| |Description of reason for topical therapy, required when response to | | | |
| |Drug Prescribed, Topical Therapy - Reason equals "OTH" Other. | | | |
|90430-7 |IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS | |1,1 | |
| |Diagnosis information related to the prescribed drug. | | | |
|90431-7 |IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS |CE |1,1 |IC9 |
| |This is the related diagnosis of the patient for which the drug is a | | |IC10 |
| |prescribed therapy. | | | |
| | | | | |
| |Note: Prior to U.S. adoption of ICD-10-CM, use ICD-9-CM in the U.S. | | | |
| |domain. After adoption as the standard for defining diagnoses in the | | | |
| |US, use only ICD-10-CM for requests in the US. | | | |
| 90432-7 |IMIDAZOLE-RELATED ANTIFUNGALS, DIAGNOSIS CONFIRMED BY |CE |0,n |HL79070 |
| |This conveys the diagnostic procedures used to establish the | | | |
| |diagnosis. | | | |
| | | | | |
| |See section 5 for the list of valid codes. | | | |
| |IMIDAZOLE-RELATED ANTIFUNGALS, DIAGNOSIS CONFIRMED BY - OTHER |TX |0,1 | |
|90433-7 |Name/description of other test used to confirm the diagnosis. Required| | | |
| |when the answer to Patient History, Diagnosis Confirmed equals "OTH" | | | |
| |Other. | | | |
|90440-7 |FUNGAL INFECTION INFORMATION | |1,1 | |
| |Information about the fungal infection. | | | |
|90441-7 |FUNGAL INFECTION INFORMATION, LOCATION |CE |1,n |HL79071 |
| |This defines the general site of the fungal infection. | | | |
| | | | | |
| |FN Finger Nail | | | |
| |TN Toe Nail | | | |
| |OTH Other (If used, then Fungal Infection Information, Location – | | | |
| |Other must be completed) | | | |
|90442-7 |FUNGAL INFECTION INFORMATION, LOCATION – OTHER |TX |0,1 | |
| |Description of the location of the fungal infection. Required when | | | |
| |Fungal Infection Information, Location equals "OTH" Other | | | |
|90443-7 |FUNGAL INFECTION INFORMATION, NUMBER OF NAILS |NM |0,1 |iso+ |
| |Enumerates the number of affected finger and or toe nails. | | | |
|90450-7 |IMMUNE COMPROMISE INFORMATION | |0,n | |
| |Information regarding the source and verification of the patient’s | | | |
| |immune compromise. | | | |
|90451-7 |IMMUNE COMPROMISE INFORMATION, CAUSE |CE |1,n |HL79072 |
| |This conveys the cause of the patient's immune compromise. | | | |
| | | | | |
| |DIS Disease | | | |
| |TRP Transplant | | | |
| |MED Medical Intervention | | | |
| |NA Not Applicable | | | |
|90452-7 |IMMUNE COMPROMISE INFORMATION, VERIFIED BY |CE |0,n |HL79073 |
| |This identifies the laboratory procedure used to verify immune | | | |
| |compromise. | | | |
| | | | | |
| |CD4 CD4 Count | | | |
| |ANC ANC Count | | | |
| |WBC White Blood Cell Count | | | |
|90460-7 |Co-morbid Conditon Information | |0,1 | |
| |Information regarding the presence of other conditions as factor in | | | |
| |the existence and treatment of the fungal infection. | | | |
| |Co-morbid Conditon Information, LIVER DYSFUNCTION Indicator | |0,1 |HL70136 |
|90461-7 |This provides information regarding the presence of liver dysfunction | | | |
| |as factor in the continuation and treatment of the fungal infection.. | | | |
| | | | | |
| |N No | | | |
| |Y Yes | | | |
|90462-7 |Co-morbid Conditon Information, LIVER DYSFUNCTION - CONFIRMED BY |CE |1,1 |HL79074 |
| |This defines the tests used to verify the liver dysfunction. | | | |
| | | | | |
| |See section 5 for the list of valid codes. | | | |
|90463-7 |Co-morbid Conditon Information, LIVER DYSFUNCTION COMFIRMED BY – OTHER|TX |0,1 | |
| |Description of test used to confirm Liver Dysfunction. Required when | | | |
| |the response to Co-morbid Condition Information, Liver Dysfunction - | | | |
| |Confirmed By equals "OTH" Other. | | | |
| |Comorbid Conditon Information, MEDICARE ESRD CERTIFICATION - |CE |1,1 |H70136 |
|90464-7 |Indicator | | | |
| |This provides information regarding the presence of End Stage Renal | | | |
| |Disease as factor in the continuation and treatment of the fungal | | | |
| |infection, based on Medicare ESRD certification. | | | |
| | | | | |
| |Y Yes | | | |
| |N No | | | |
|90070-x |MEDICARE ESRD CERTIFICATION DATE | |0,1 | |
| |Date patient was certified by Medicare as having End Stage Renal | | | |
| |Disease | | | |
|90070-x |. |DT |1,1 | |
| | | | | |
|90470-7 |LEVEL OF FUNCTIONAL IMPAIRMENT | |0,1 | |
| |This conveys functional limitations resulting from or exacerbating the| | | |
| |fungal infection. | | | |
|90470-7 | |CE |1,n | HL79075 |
| |See section 5 for the list of valid codes. | | | |
|90480-7 |INPATIENT TREATMENT Information | |0,1 | |
| |Required if the patient is being discharged from an inpatient hospital| | | |
| |stay during which anti-fungal treatment was administered. | | | |
|90481-7 |INPATIENT TREATMENT Information, IV Anti-Fungal Therapy Indicator |CE |1,1 |HL70136 |
| |Indicator to define whether IV Anti-fungal therapy was provided during| | | |
| |the admission. | | | |
| | | | | |
| |N No | | | |
| |Y Yes | | | |
|90482-7 |INPATIENT TREATMENT Information, IV Anti-Fungal Therapy – Agent(s) |TX |0,1 | |
| |Name of the IV Therapy Agents given during the hospital stay. | | | |
|90080-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS | |0,n | |
| |Information about other drugs previously prescribed for treatment of | | | |
| |this condition with less than optimal outcomes. | | | |
|90081-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG NAME |TX |1,1 | |
| |This is the descriptive name of the drug previously used to treat the | | | |
| |diagnosis. | | | |
|90082-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG CODE |CE |1,1 |NDC |
| |The code assigned to the drug previously used to treat the diagnosis | | |RxNorm SCD |
| |as defined by: Representative NDC, RxNorm SCD or RxNorm SBD | | |RxNorm SBD |
|90083-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DURATION OF THERAPY |NM |1,1 |iso+ |
| |Duration of previous therapy in days. | | | |
|90084-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON(S) PRIOR THERAPY |CE |1,1 |HL79040 |
| |DISCONTINUED | | | |
| |This is the reason that the prior drug therapy was discontinued. | | | |
| | | | | |
| |NTEFF Not or No Longer Effective | | | |
| |SDEFT Side Effects/Tolerance | | | |
| |NTCMP Not Compatible | | | |
| |OTH Other | | | |
|90085-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS, REASON PRIOR THERAPY |TX |0,1 | |
| |DISCONTINUED – OTHER | | | |
| |Description of the other reason for discontinued therapy. If Drug | | | |
| |History, Prior Therapy for Diagnosis - Reason Prior Therapy | | | |
| |Discontinued equals "OTH" Other, then this is required. | | | |
|90086-x |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - INCOMPATIBLE DRUG NAME |TX |0,n | |
| |The descriptive name of the drug(s) incompatible with the prior | | | |
| |therapy. If Drug History, Prior Therapy for Diagnosis - Reason Prior | | | |
| |Therapy Discontinued equals "NTCMP" Not Compatible, then this is | | | |
| |required. | | | |
|90490-7 |IMIDAZOLE-RELATED ANTIFUNGALS, PRIOR THERAPY TYPE | | | |
| |The route of the previously used medication for treatment of the | | | |
| |fungal infection. | | | |
| |IMIDAZOLE-RELATED ANTIFUNGALS, PRIOR THERAPY TYPE |CE |0,1 |HL79076 |
|90490-7 |Type of drug therapy previously used for treatment of the fungal | | | |
| |infection. | | | |
| | | | | |
| |ORL Oral | | | |
| |TOP Topical | | | |
| |INJ Injectible | | | |
| |IV Intravenous | | | |
|90090-x |CONCURRENT THERAPY | |0,n | |
| |Drugs the patient is currently on, for this or other diagnoses, which | | | |
| |may impact the requested drug. | | | |
|90091-x |CONCURRENT THERAPY, DRUG NAME |TX |0,1 | |
| |This is the descriptive name of the drugs) the patient is currently | | | |
| |on, for this or other diagnoses, which might impact the requested | | | |
| |drug. | | | |
|90092-x |CONCURRENT THERAPY, DRUG CODE |CE |1,1 |NDC |
| |The code assigned to the concurrent drug as defined by: | | |RxNorm SCD |
| |Representative NDC, RxNorm SCD, or RxNorm SBD | | |RxNorm SBD |
Coding Examples
1 Scenario
Sara J. Smith is a 50 year old female receiving care for hepatic dysfunction and a persistent fungal infection of her right foot. She returned to her physician, Robert J Podell, MD, a Hepatologist (Taxonomy 207RI0008X) for a follow-up evaluation on 12/28/2005. Ms. Smith’s medical record number is 184569
The findings at this time revealed that the medication, Tinactin Cream, had not proved effective in controlling the Tenea Pedis infection. Because of her diminished liver function Ms. Smith is unable to take a systemic anti-fungal medication, so Dr. Podell decides to order Oxistat Cream, 1%, 60 gram tube (NDC-0173-0423-04) as a replacement therapy.
Ms. Smith has medical and drug coverage through Aetna Insurance, Plan ID 10567432.Her Aetna patient ID is 352584768003G. The Plan’s drug benefit is administered by ReadiRx PBM. On checking the Plan formulary, Dr. Podell finds that Oxistat Cream is a covered benefit requiring prior authorization. Using the Plan’s Antifungal PA Attachment and criteria for coverage of coverage of Oxistat Cream, he reviews Ms. Smith’s medical record to assure that she meets the criteria and to collect the information needed for the request. Dr. Podell’s Aetna provider ID is 4376557IM.
The following information was collected from the medical record. The diagnosis requiring the use of the ordered drug is 110.4 - Tinea Pedis. This diagnosis was confirmed by KOH Preparation performed on 9/15/2004. The use of a topical drug is required because of Liver Dysfucntion as confirmed by a 7/15/2004 Hepatic Function Panel. The fungal infection is located between the toes of her right foot and at this point is not causing or impacted by any function limitations. The previous treatment which proved ineffective, was with Tinactin Cream, NDC-0085-0715-07.
The request associated with this CDA document is identified by the value XA728302 as it’s attachment control number. This is used for linking purposes within the 278 and 275.
Figure 4.1 Drug Prior Authorization Additional Data
PRESCRIBER NAME Podell MD, Robert J
PRESCRIBER IDENTIFIER 4376557IM
PRESCRIBER TAXONOMY 207RI0008X
PRESCRIBER CONTACT PHONE # 765-228-1234
PRESCRIBER CONTACT FAX # 765-228-3123
DRUG PRESCRIBED, NAME (TEXT) Oxistat, Cream, 1%, 60-g tube
DRUG PRESCRIBED, DRUG CODE 0173-0423-04
DRUG PRESCRIBED, THERAPY TYPE Replacement (RPLRQ)
DRUG PRESCRIBED, REASON FOR Hepatic Dysfunction (HDS)
TOPICAL THERAPY
RELATED DIAGNOSIS (TEXT) Tinea Pedia
RELATED DIAGNOSIS (CODE) 110.4
RELATED DIAGNOSIS CONFIRMED BY KOH Preparation (KOH)
INFECTION LOCATION Between toes, right foot (OTH)
LIVER DYSFUNCTION INDICATOR Yes (Y)
LIVER DYSFUNTION CONFIRMED BY Hepatic Function Panel (HFP)
MEDICARE ESRD CERTIFICATION Yes (Y)
INDICATOR
PRIOR THERAPY, DRUG NAME Tinactin, Cream
PRIOR THERAPY, DRUG CODE 0085-0715-07
PRIOR THERAPY, DURATION 90 days
PRIOR THERAPY, RREASON PRIOR Not or no longer effective (NTEFF)
THERAPY DISCONTINUED
PRIOR THERAPY, TYPE Topical (TOP)
1 Drug Prior Authorization Attachment, Human-Decision Variant (XML body)
The right column of the example below contains the single HL7 document in the human-decision variant that conveys this report in its entirety. The left column provides help in relating the example to the scenario and to the Value Table.
Example 4.1.1 Drug Prior Authorization Attachment, Human-Decision Variant (XML body)
|Header | |
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|Provider Identification| |
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|Patient Identification | |
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|Attachment Control | |
|Number | |
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|Prescriber Information | |
|(Name, Identifier and | |
|Taxonomy) |PRESCRIBER INFORMATION |
| | |
| |PRESCRIBER INFORMATION, NAME |
| |Robert J. Podell, MD |
| | |
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| |PRESCRIBER INFORMATION, IDENTIFIER |
| |4376557IM |
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| |PRESCRIBER INFORMATION, SPECIALTY TAXONOMY |
| |Hepatologist (207RI0008X) |
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|Prescriber Contact | |
|Information (phone and |PRESCRIBER CONTACT INFORMATION |
|fax numbers) | |
| |PRESCRIBER CONTACT INFORMATION, PHONE NUMBER |
| |(765) 228-1234 |
| | |
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| |PRESCRIBER CONTACT INFORMATION, FAX NUMBER |
| |(765) 228-3123 |
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|Drug Prescribed | |
|Information (Name of |DRUG PRESCRIBED |
|Drug, Drug Code and | |
|Therapy Type) |DRUG PRESCRIBED, NAME |
| |Oxistat Cream, 1%, 60g tube |
| | |
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| |DRUG PRESCRIBED, DRUG CODE |
| |0173-0423-04 (NDC) |
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| |DRUG PRESCRIBED, THERAPY TYPE |
| |Replacement (RPLRQ) |
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|Drug Prescribed, Reason| |
|for Topical Therapy |DRUG PRESCRIBED, REASON FOR TOPICAL THERAPY |
| | |
| |Hepatic Dysfunction (HDS) |
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|Related Diagnosis | |
|Information (Diagnosis |IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS |
|Description and Code | |
|and how the diagnosis |IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS |
|was confirmed) |Tinea Pedia (ICD-9-CM 110.4) |
| | |
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| |IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS - CONFIRMED BY |
| |KOH Preparation (KOH) |
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|Fungal Infection | |
|Location |FUNGAL INFECTION LOCATION |
| | |
| |Between Toes, right foot (OTH) |
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|Liver Dysfunction | |
|Information (Indicator |CO-MORBID CONDITION INFORMATION |
|and how it was | |
|confirmed) |CO-MORBID CONDITION INFORMATION, LIVER DYSFUNCTION INDICATOR |
| |yes (Y) |
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| |CO-MORBID CONDITION INFORMATION, LIVER DYSFUNCTION CONFIRMED BY |
| |Hepatic Function Panel (HFP) |
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|Medicare ESRD | |
|Certification Indicator|MEDICARE ESRD CERTIFICATION INDICATOR |
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| |Yes (Y) |
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|Drug History, Prior | |
|Therapy for Diagnosis |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS |
|(Prior Therapy Drug | |
|Name, Code, Duration, |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG NAME |
|and Reason for |Tinactin Cream |
|Discontinuance) | |
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| |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG CODE |
| |0085-0715-07 (NDC) |
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| |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DURATION OF THERAPY |
| |90 days |
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| |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR THERAPY DISCONTINUED |
| |Not or no longer effective (NTEFF) |
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|Prior Therapy Type | |
| |IMIDAZOLE-RELATED ANTIFUNGALS, PRIOR THERAPY TYPE |
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| |Topical (TOP) |
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Figure 1 shows the human-decision variant (XML body) as rendered by a popular browser.
Figure 1. Rendered Human-Decision Variant (XML body)
Drug Prior Authorization Attachment
|Provider: |Robert J Podell, MD |
|Patient: |Sara J Smith |Provider's Pt ID: |352584768003G |
|Attachment Control Number: |XA728302 | |
[pic]
PRESCRIBER INFORMATION
PRESCRIBER INFORMATION, NAME. Robert J. Podell, MD
PRESCRIBER INFORMATION, IDENTIFIER. 4376557IM
PRESCRIBER INFORMATION, SPECIALTY TAXONOMY. Hepatologist (207RI0008X)
PRESCRIBER CONTACT INFORMATION
PRESCRIBER CONTACT INFORMATION, PHONE NUMBER. (765) 228-1234
PRESCRIBER CONTACT INFORMATION, FAX NUMBER. (765) 228-3123
DRUG PRESCRIBED
DRUG PRESCRIBED, NAME. Oxistat Cream, 1%, 60g tube
DRUG PRESCRIBED, DRUG CODE. 0173-0423-04 (NDC)
DRUG PRESCRIBED, THERAPY TYPE. Replacement (RPLRQ)
DRUG PRESCRIBED, REASON FOR TOPICAL THERAPY
Hepatic Dysfunction (HDS)
IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS
IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS. Tinea Pedia (ICD-9-CM 110.4)
IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS - CONFIRMED BY. KOH Preparation (KOH)
FUNGAL INFECTION LOCATION
Between Toes, right foot (OTH)
CO-MORBID CONDITION INFORMATION
CO-MORBID CONDITION INFORMATION, LIVER DYSFUNCTION INDICATOR. yes (Y)
CO-MORBID CONDITION INFORMATION, LIVER DYSFUNCTION CONFIRMED BY. Hepatic Function Panel (HFP)
MEDICARE ESRD CERTIFICATION INDICATOR
Yes (Y)
DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS
DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG NAME. Tinactin Cream
DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG CODE. 0085-0715-07 (NDC)
DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DURATION OF THERAPY. 90 days
DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR THERAPY DISCONTINUED. Not or no longer effective (NTEFF)
IMIDAZOLE-RELATION ANTIFUNGALS, PRIOR THERAPY TYPE
Topical (TOP)
2 Drug Prior Authorization Attachment, Human-Decision Variant (non-XML body)
The right column of the example below contains the single HL7 Additional Information CDA document in the human-decision variant that conveys this report in its entirety. The left column provides help in relating the example to the scenario and to the Value Table.
Example 4.1.2 Drug Prior Authorization Attachment, Human-Decision Variant (non-XML body)
|Header | |
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|Provider Identification| |
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|Patient Identification | |
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|Attachment Control | |
|Number | |
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|MIME Reference for | |
|Antifungal Report | |
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|Base64 Encoded |--192.168.0.132.1.111780.1044168570.525.24086 |
|Antifungal Report (this|Content-Type: image/tif |
|is an example of a |Content-Transfer-Encoding: base64 |
|portion of the MIME |Content-Disposition: attachment; filename=Antifungal report.tif |
|packaging) | |
| |R0lGODlhAAJ9AfAAAP///wAAACwAAAAAAAJ9AUAC/wQShrqcb06SrNITm57bTvqB0dWRUMal |
| |nmqubkuib0lDyHIrYz2zPPzDZUbEou5oJNpiuVPDIXngptIqkIP5aFesq2eIDGLDPhksiU47 |
| |nsVbiOqeotjtnPp+f8a17FAFTrez95Yid6FkZ4e24cdocSiIJzlJWWl5WekWNVjot9kUZ8YZ |
| |tfmpF/q5VmWFmRl4xBkrO6topNmKm6u7y9vr+/u7J+k5WVure5wJlhTafKuICrwGBkhrfS2c |
| |(Editor’s note: 149 lines have been suppressed for readability.) |
| |SmW6Sr0UTL2M5ut4yN5k7soG7vici6fc6QHbTh+khPZMrOHMrvfaCpkaUNm0rvTUBcSEJ6cQ |
| |o+wwjU0oJrAQ74fqZ+jewudY7N5KEOPm6rVEcMoOqbVaD/1ubkQyba+eiRj0TwZ/LteWkAmt |
| |Yf8QcMwmRGuCkAajRZjSYm+ojQq30FL6zu24EAzrJ8XCkAzl4fTKEA3TUA3XkA3b0A3fEA7j |
| |0C0IAAUAOw== |
| |--192.168.0.132.1.111780.1044168570.525.24086 |
Figure 2 shows the human-decision variant (non-XML body) as rendered by a popular browser.
Figure 2. Rendered Human-Decision Variant (non-XML body)
Imidazol-Related Antifungals Attachment
|Provider: |Robert J Podell, MD |
|Patient: |Sara J Smith |Provider's Pt ID: |352584768003G |
|Attachment Control Number: |XA728302 | |
[pic]
Click here to view report.
[pic]
3 Coded Drug Prior Authorization Attachment, Computer-Decision Variant
The right column of the example below contains the single HL7 Additional Information CDA document in the computer-decision variant that conveys this report in its entirety. The left column provides help in relating the example to the scenario and to the Value Table.
Example 4.1.2 Drug Prior Authorization Attachment, Computer-Decision Variant
|Header | |
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|Provider Identification| |
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|Patient Identification | |
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|Attachment Control | |
|Number | |
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|Prescriber Information | |
|(Name, Identifier and | |
|Taxonomy) |PRESCRIBER INFORMATION |
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| |PRESCRIBER INFORMATION, NAME |
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| |Robert J. Podell, MD |
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| |ROBERT |
| |J |
| |PODELL |
| |MD |
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| |PRESCRIBER INFORMATION, IDENTIFIER |
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| |4376557IM |
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| |PRESCRIBER INFORMATION, SPECIALTY TAXONOMY |
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| |207RI0008X Hepatologist |
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|Prescriber Contact | |
|Information (phone and |PRESCRIBER CONTACT INFORMATION |
|fax numbers) | |
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| |PRESCRIBER CONTACT INFORMATION, PHONE NUMBER |
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| |(765)228-1234 |
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| |PRESCRIBER CONTACT INFORMATION, FAX NUMBER |
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| |(765)228-3123 |
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|Drug Prescribed | |
|Information (Name of |DRUG PRESCRIBED |
|Drug, Drug Code and | |
|Therapy Type) | |
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| |DRUG PRESCRIBED, NAME |
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| |Oxistat Cream, 1%, 60g tube |
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| |DRUG PRESCRIBED, DRUG CODE |
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| |0173-0423-04 Oxistat Cream, 1%, 60g tube |
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| |DRUG PRESCRIBED, THERAPY TYPE |
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| |Replacement (RPLRQ) |
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|Drug Prescribed, Reason| |
|for Topical Therapy |DRUG PRESCRIBED, REASON FOR TOPICAL THERAPY |
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| |Hepatic Dynsfunction (HDS) |
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|Related Diagnosis | |
|Information (Diagnosis |IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS |
|Description and Code | |
|and how the diagnosis | |
|was confirmed) | |
| |IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS |
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| |Tinea Pedia 110.4 (ICD-9-CM) |
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| |IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS - CONFIRMED BY |
| | |
| |KOH Preparation (KOH) |
| | |
| | |
| | |
| | |
| | |
| | |
|Fungal Infection | |
|Location |FUNGAL INFECTION LOCATION - OTHER |
| | |
| | |
| | |
| |Between toes, right foot |
| | |
| | |
|Co-Morbid Condition | |
|Information (Liver |CO-MORBID INFORMATION |
|Dysfunction) (Indicator| |
|and how it was | |
|confirmed) | |
| |CO-MORBID INFORMATION, LIVER DYSFUNCTION INDICATOR |
| | |
| | |
| |Yes (Y) |
| | |
| | |
| | |
| | |
| | |
| | |
| |CO-MORBID INFORMATION, LIVER DYSFUNCTION CONFIRMED BY |
| | |
| | |
| |Hepatic Function Panel (HFP) |
| | |
| | |
| | |
| | |
| | |
| | |
|Medicare ESRD | |
|Certification Indicator|MEDICARE ESRD CERTIFICATION INDICATOR |
| | |
| | |
| | |
| |Yes (Y) |
| | |
| | |
| | |
| | |
| | |
| | |
|Drug History, Prior | |
|Therapy for Diagnosis |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS |
|(Prior Therapy Drug | |
|Name, Code, Duration, | |
|and Reason for | |
|Discontinuance) |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG NAME |
| | |
| | |
| |Tinactin Cream |
| | |
| | |
| |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG CODE |
| | |
| | |
| |0085-0715-07 (NDC) |
| | |
| | |
| | |
| | |
| | |
| | |
| |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DURATION OF THERAPY |
| | |
| | |
| |90 days |
| |90 |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR THERAPY DISCONTINUED |
| | |
| | |
| |Not or no longer effective (NTEFF) |
| | |
| | |
| | |
| | |
| | |
| | |
|Prior Therapy Type | |
| |DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR THERAPY DISCONTINUED |
| | |
| | |
| | |
| |Topical (TOP) |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
Figure 3 shows a portion of the computer-decision variant as rendered by a popular browser. It includes the medications rendered as a table.
Figure 3. Rendered Human-Decision Variant (non-XML body)
Imidazol-Related Antifungals Attachment
|Provider: |Robert J Podell, MD |
|Patient: |Sara J Smith |Provider's Pt ID: |352584768003G |
|Attachment Control Number: |XA728302 | |
[pic]
PRESCRIBER INFORMATION
PRESCRIBER INFORMATION, NAME. Robert J. Podell, MD
PRESCRIBER INFORMATION, IDENTIFIER. 4376557IM
PRESCRIBER INFORMATION, SPECIALTY TAXONOMY. 207RI0008X Hepatologist
PRESCRIBER CONTACT INFORMATION
PRESCRIBER CONTACT INFORMATION, PHONE NUMBER. (765)228-1234
PRESCRIBER CONTACT INFORMATION, FAX NUMBER. (765)228-3123
DRUG PRESCRIBED
DRUG PRESCRIBED, NAME. Oxistat Cream, 1%, 60g tube
DRUG PRESCRIBED, DRUG CODE. 0173-0423-04 Oxistat Cream, 1%, 60g tube
DRUG PRESCRIBED, THERAPY TYPE. Replacement (RPLRQ)
DRUG PRESCRIBED, REASON FOR TOPICAL THERAPY
Hepatic Dynsfunction (HDS)
IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS
IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS. Tinea Pedia 110.4 (ICD-9-CM)
IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS - CONFIRMED BY. KOH Preparation (KOH)
FUNGAL INFECTION LOCATION - OTHER
Between toes, right foot
CO-MORBID INFORMATION
CO-MORBID INFORMATION, LIVER DYSFUNCTION INDICATOR. Yes (Y)
CO-MORBID INFORMATION, LIVER DYSFUNCTION CONFIRMED BY. Hepatic Function Panel (HFP)
MEDICARE ESRD CERTIFICATION INDICATOR
Yes (Y)
DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS
DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG NAME. Tinactin Cream
DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG CODE. 0085-0715-07 (NDC)
DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DURATION OF THERAPY. 90 days
DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR THERAPY DISCONTINUED. Not or no longer effective (NTEFF)
DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR THERAPY DISCONTINUED
Topical (TOP)
Response Code Sets
This section describes response codes that may be used in the computer-decision variant when the value table indicates a coded with exception (CE) data type or to represent units when the attachment component is of the numeric (NM) data type. The entry in the value table that refers to these code sets is used in the subsection titles.
The values for some code sets appear directly in this document. In other cases, the section cites another document as the source.
1 HL70136: Yes-No Indicator
The OID for this table is 2.16.840.1.113883.12.136.
Table 5.1 Yes-No Indicator
|Code |Description |Additional Comments |
|N |No | |
|Y |Yes | |
2 HL79038: Drug Prescribed, Therapy Type
The OID for this table is 2.16.840.1.113883.12.9038.
Table 5.2 Drug Prescribed, Therapy Type
|Code |Description |Additional Comments |
|INTRQ |Initial Therapy | |
|CNTRQ |Continued Therapy | |
|RPLRQ |Replacement Therapy | |
|ADDRQ |Add-on Therapy | |
3 HL79039: UTC, Diagnosis Confirmed By
The OID for this table is 2.16.840.1.113883.12.9039.
Table 5.3 UTC, Diagnosis Confirmed By
|Code |Description |Additional Comments |
|LABT |Laboratory Examination | |
|RADT |Radiological Examination | |
|OTDX |Other Diagnostic Examination | |
|CLNE |Clinical Evaluation | |
4 HL79040: Reason Prior Therapy Discontinued
The OID for this table is 2.16.840.1.113883.12.9040.
Table 5.4 Reason Prior Therapy Discontinued
|Code |Description |Additional Comments |
|NTEFF |Not or No Longer Effective | |
|SDEFT |Side Effects/Tolerance | |
|NTCMP |Not Compatible |Not compatible with other required |
| | |drugs. |
|OTH |Other |If used, then Reason Prior Therapy |
| | |Discontinued – Other must be completed |
5 HL79041: NSAIDS/PPI Related Concurrent Therapy, Type
The OID for this table is 2.16.840.1.113883.12.9041.
Table 5.5 NSAIDS – COX 2 Inhibitors, Concurrent Therapy - Type
|Code |Description |Additional Comments |
|CRTC |Corticosteroid | |
|ANCG |Anti-coagulant | |
|ANPL |Anti-platelet | |
|PPI |Proton Pump Inhibitor | |
|H2RA |H2 Receptor Antagonist | |
|NSAD |NSAIDS | |
|BPHN |Biphosphonate | |
|ANNP |Anti-neoplastic | |
|FAP |For Familial Adenomatous Polposis | |
|ASAL |ASA325mg/day | |
|OTH |Other |If used, then Drug History, Other Drug |
| | |Type must be completed. |
6 HL79042: NSAID Use, Duration
The OID for this table is 2.16.840.1.113883.12.9042.
Table 5.6 NSAID Use, Duration
|Code |Description |Additional Comments |
|G21 |NSAID Use greater than 21 days | |
|L21 |NSAID Use less than 21 days | |
7 HL79043: Yes-No-Unknown Indicator
The OID for this table is 2.16.840.1.113883.12.9043.
Table 5.7 HL7 NSAID Use, Duration
|Code |Description |Additional Comments |
|Y |Yes | |
|N |No | |
|U |Unknown | |
8 HL79044: Radiology Diagnosis Confirmation, Study Type
The OID for this table is 2.16.840.1.113883.12.9044.
Table 5.8 Radiology Diagnosis Confirmation, Study Type
|Code |Description |Additional Comments |
|BAE |Bone Age | |
|BDY |Bone Density | |
|MRI |Magnetic Resonance Imaging (MRI) | |
|ESX |X-Ray to Determine Epiphyseal Status | |
9 HL79045: Laboratory Diagnosis Confirmation, Study/Test
The OID for this table is 2.16.840.1.113883.12.9045.
Table 5.9 Laboratory Diagnosis Confirmation, Study/Test
|Code |Description |Additional Comments |
|IGB3 |IGFBP3 | |
|IGF1 |IGF1 | |
|ITT |Insulin Tolerance | |
|ACTH |ACTH | |
|TSH |TSH | |
|LIP |Lipid Level | |
|GHA |Combined GHRH and Arginine |If ITT contraindicated. |
|GTP |Gonadotropin | |
|FTST |Free Testosterone | |
|GT |Genetic Testing | |
|OTH |Other |If used, then Laboratory Diagnosis |
| | |Confirmation Information, Other |
| | |Study/Test Name must be used. |
10 HL79046: GH, Patient History – Documented Onset
The OID for this table is 2.16.840.1.113883.12.9046.
Table 5.10 GH, Patient History – Documented Onset
|Code |Description |Additional Comments |
|AO |Adult Onset | |
|CO |Childhood Onset | |
|UO |Unknown Onset | |
11 HL79047: GH, Patient History Information – Hypothalmic Pituitary Disease Induced By
The OID for this table is 2.16.840.1.113883.12.9047.
Table 5.11 GH, Patient History Information – Hypothalmic Pituitary Disease Induced By
|Code |Description |Additional Comments |
|PTT |Pituitary Tumor | |
|IRR |Irradiation | |
|SUG |Surgery | |
|HMN |Hormone Dysfunction or Therapy | |
|TRA |Trauma | |
12 HL79048: Treatment Status
The OID for this table is 2.16.840.1.113883.12.9048.
Table 5.12 Treatment Status
|Code |Description |Additional Comments |
|AT |In Progress/Active Treatment | |
|IT |Initial Course of Treatment | |
|CP |Completed | |
|PT |Previously Treated | |
|NT |New Course of Treatment | |
|PL |Planned | |
13 HL79049: GHD Childhood Information, Puberty Status
The OID for this table is 2.16.840.1.113883.12.9049.
Table 5.13 GHD Childhood Information, Puberty Status
|Code |Description |Additional Comments |
|BP |Pre-pubertal | |
|AP |Post Pubertal | |
|PS |Pubertal | |
14 HL79050: GH Dysfunction Adult Information, Secondary Causes
The OID for this table is 2.16.840.1.113883.12.9050.
Table 5.14 GH Dysfunction Adult Information, Secondary Causes
|Code |Description |Additional Comments |
|A |Age | |
|O |Obesity | |
|D |Depression | |
|O |Other |If used, then Secondary Causes Other |
| | |must be completed. |
15 HL79051: Nutritional Information, Assessment Indicator
The OID for this table is 2.16.840.1.113883.12.9051.
Table 5.15 Nutritional Information, Assessment Indicator
|Code |Description |Additional Comments |
|CMP |Completed | |
|PLD |Planned | |
16 HL79052: Parental Height, Availability Indicator
The OID for this table is 2.16.840.1.113883.12.9052.
Table 5.16 Parental Height, Availability Indicator
|Code |Description |Additional Comments |
|MK |Mother Known | |
|FK |Father Known | |
|BK |Both Known | |
|BU |Both Unknown | |
17 HL79053: Diagnosis Confirmation and Level of Treatment Needed, Procedure Employed
The OID for this table is 2.16.840.1.113883.12.9053.
Table 5.17 Diagnosis Confirmation and Level Treatment Needed, Procedure Employed
|Code |Description |Additional Comments |
|BMS |Barium Studies | |
|EGD |Endoscopy | |
|BIO |Biopsy | |
18 HL79054: Diagnosis Confirmation and Level of Treatment Needed, GERD By Endoscopy Type
The OID for this table is 2.16.840.1.113883.12.9054.
Table 5.18 Diagnosis Confirmation and Level of Treatment Needed, GERD By Endoscopy Type
|Code |Description |Additional Comments |
|ERSV1 |Erosive Grade 1 | |
|ERSV2 |Erosive Grade 2 | |
|ERSV3 |Erosive Grade 3 | |
|ERSV4 |Erosive Grade 4 | |
|NERSV |Non Erosive | |
19 HL79055: H-Pylori Information, Status
The OID for this table is 2.16.840.1.113883.12.9055.
Table 5.19 H-Pylori Information, Status
|Code |Description |Additional Comments |
|PS |Positive | |
|NE |Negative | |
20 HL79056: H-Pylori Information, Confirmed By
The OID for this table is 2.16.840.1.113883.12.9056.
Table 5.20 H-Pylori Information, Confirmed By
|Code |Description |Additional Comments |
|SROL |Serology | |
|URBT |Urease Breath Test | |
|FSGS |Feasting Serum Gastrin | |
|B1HA |Basal 1 Hour Acid Output | |
|SCST |Secretion Simulation Test | |
|OTH |Other |If used, then H-Pylori Information |
| | |Confirmed by Other is required. |
21 HL79057: ED, Related Diagnosis Confirmation, Confirmed By
The OID for this table is 2.16.840.1.113883.12.9057.
Table 5.21 ED, Related Diagnosis Confirmation, Confirmed By
|Code |Description |Additional Comments |
|TST |Tertosterone Level | |
|PRL |Prolactin Level | |
|THY |Thyroid Level | |
|NA |Not Applicable | |
|OTH |Other Test |If used, then ED, Related Diagnosis |
| | |Confirmation, Confirmed By Other is |
| | |required. |
22 HL79058: ED, Patient History – Pulmonary Hypertension Functional Level
The OID for this table is 2.16.840.1.113883.12.9058.
Table 5.22 ED, Patient History – Pulmonary Hypertension Functional Level
|Code |Description |Additional Comments |
|C1 |Class I | |
|C2 |Class II | |
|C3 |Class III | |
|C4 |Class IV | |
23 HL79059: ED, Patient History – Evaluation Type
The OID for this table is 2.16.840.1.113883.12.9059.
Table 5.23 ED, Patient History – Evaluation Type
|Code |Description |Additional Comments |
|GH |General Health Status Evaluation | |
|UC |Investigation of Underlying Causes of Primary Condition | |
|NA |Not Applicable | |
24 HL79060: ED, Patient History – ED Related To
The OID for this table is 2.16.840.1.113883.12.9060.
Table 5.24 ED, Patient History – ED Related To
|Code |Description |Additional Comments |
|END |Endocrine Disorder | |
|URS |Urogenital Surgery | |
|SPC |Spinal Cord Injury | |
|TSC |Testicular Cancer | |
|PSG |Psychogenic | |
25 HL79061: ED, Treatment of Related Causes – Psychogenic Causes of ED Treatment
The OID for this table is 2.16.840.1.113883.12.9061.
Table 5.25 ED, Treatment of Related Causes – Psychogenic Causes of ED Treatment
|Code |Description |Additional Comments |
|PSY |Psychotherapy | |
|BHT |Behavior Therapy | |
|OTT |Other Therapy | |
|NOT |No Treatment | |
26 HL79062: ED, Treatment of Related Causes – Drug Induced Option
The OID for this table is 2.16.840.1.113883.12.9062.
Table 5.26 ED, Treatment of Related Causes – Drug Induced Option
|Code |Description |Additional Comments |
|RDU |Reduction in Drug Use | |
|DCT |Discontinue Drug Use | |
|CGD |Change Drug | |
|DCN |Drug Cannot be Change or Discontinued | |
27 HL79063: ED Concurrent Therapy, Type
The OID for this table is 2.16.840.1.113883.12.9063.
Table 5.27 ED Concurrent Therapy, Type
|Code |Description |Additional Comments |
|NTT |Nitrate | |
|APB |Alpha-Blocker | |
|SRI |SSRI | |
|PGN |Prostaglandin for PPH | |
|ETA |Endothelium for PAH | |
|VDP |Vasodilator for PAH | |
|OED |Other ED Medication |If used, then ED Concurrent Therapy, |
| | |Other Type is required. |
28 HL79064: Narcotic (Opioid) Agonists, Patient History – Pain Syndrome Source
The OID for this table is 2.16.840.1.113883.12.9064.
Table 5.28 Narcotic (Opioid) Agonists, Patient History – Pain Syndrome Source
|Code |Description |Additional Comments |
|BPN |Bone Pain | |
|JPN |Joint Pain | |
|MST |Other Somatic Pain (Muscle./Soft Tissue) | |
|VPN |Visceral Pain | |
|NPN |Neuropathic Pain | |
|OTH |Other Pain Syndrome |If used, then Pain Syndrome Other is |
| | |required. |
29 HL79065: Narcotic (Opioid) Agonists, Patient History – Pain Syndrome History
The OID for this table is 2.16.840.1.113883.12.9065.
Table 5.29 Narcotic (Opioid) Agonists, Patient History – Pain Syndrome History
|Code |Description |Additional Comments |
|CP |Constant Pain | |
|ITP |Intermittent Pain | |
|ICP |Incidental Pain | |
30 HL79066: Narcotic (Opioid) Agonists, Patient History – Pain Syndrome Persistence
The OID for this table is 2.16.840.1.113883.12.9066.
Table 5.30 Narcotic (Opioid) Agonists, Patient History – Pain Syndrome Persistance
|Code |Description |Additional Comments |
|AL |Acute Limited – Less Than 30 Days | |
|CR |Chronic | |
|CRP |Chronic Progressive | |
|CPR |Chronic Progressive with Escalating Opioid | |
31 HL79067: Narcotic (Opioid) Agonists, Complicating Conditions
The OID for this table is 2.16.840.1.113883.12.9067.
Table 5.31 Narcotic (Opioid) Agonists, Complicating Conditions
|Code |Description |Additional Comments |
|BRA |Bronchial Asthma | |
|PAI |Paralytic Ileum |Diagnosed or suspected. |
|PSY |Psychiatric Condition | |
|LDY |Liver Dysfunction | |
|KDY |Kidney Dysfunction | |
|CRP |Other Chronic Pulmonary Condition | |
|OTH |Other |If used, then Other Complicating |
| | |Conditions is required |
32 HL79068: Opioid Related Concurrent Pain Therapy, Opioid Level
The OID for this table is 2.16.840.1.113883.12.9068.
Table 5.32 Opioid Concurrent Pain Therapy, Opioid Level
|Code |Description |Additional Comments |
|RDL |Recommended, Dose Level | |
|HPL |High Potency Dose Level | |
|24L |24 Hour High Potency Dose Level | |
|OTL |Opioid Tolerant | |
33 HL79069: Drug Prescribed, Topical Therapy - Reason
The OID for this table is 2.16.840.1.113883.12.9069.
Table 5.33 Drug Prescribed, Topical Therapy - Reason
|Code |Description |Additional Comments |
|UTS |Unable to Swallow | |
|HDS |Hepatic Dysfunction | |
|OTH |Other | |
34 HL79070: Imidazole – Related Antifungals, Diagnosis Confirmed By
The OID for this table is 2.16.840.1.113883.12.9070.
Table 5.34 Imidazole – Related Antifungals, Diagnosis Confirmed By
|Code |Description |Additional Comments |
|FCL |Fungal Culture | |
|PAS |PAS Stain Results | |
|KOH |KOH Preparation | |
|NBP |Nail Biopsy | |
|OTH |Other | |
35 HL79071: Fungal Infection Information, Location
The OID for this table is 2.16.840.1.113883.12.9071.
Table 5.35 Fungal Infection Information, Location
|Code |Description |Additional Comments |
|FN |Finger Nail | |
|TN |Toe Nail | |
|OTH |Other | |
36 HL79072: Immune Compromise Information, Cause
The OID for this table is 2.16.840.1.113883.12.9072.
Table 5.36 Immune Compromise Information, Cause
|Code |Description |Additional Comments |
|DIS |Disease | |
|TRP |Transplant | |
|MED |Medical Intervention | |
|NA |Not Applicable | |
37 HL79073: Immune Compromise Information, Verified By
The OID for this table is 2.16.840.1.113883.12.9073.
Table 5.37 Immune Compromise Information, Verified By
|Code |Description |Additional Comments |
|CD4 |CD4 Count | |
|ANC |ANC Count | |
|WBC |White Blood Cell Count | |
38 HL79074: Co-Morbid Condition Information, Liver Dysfunction – Confirmed By
The OID for this table is 2.16.840.1.113883.12.9074.
Table 5.38 Co-Morbid Condition Information, Liver Dysfunction – Confirmed By
|Code |Description |Additional Comments |
|HFP |Hepatic Function Panel | |
|TAL |SGPT, ALT | |
|TAS |SGOT, AST | |
|OTH |Other | |
39 HL79075: Level of Functional Impairment
The OID for this table is 2.16.840.1.113883.12.9075.
Table 5.39 Level of Functional Impairment
|Code |Description |Additional Comments |
|AL |Ambulation Limitations | |
|CO |Contractures | |
|DY |Dyspnea with Minimum Exertion | |
|EL |Endurance Limitations | |
|PA |Painful Ambulation | |
40 HL79076: Imidazole – Related Antifungals, Prior Therapy Type
The OID for this table is 2.16.840.1.113883.12.9076.
Table 5.40 Imidazole – Related Antifungals, Prior Therapy Type
|Code |Description |Additional Comments |
|ORL |Oral | |
|TOP |Topical | |
|INJ |Injectible | |
|IV |Intravenous | |
41 I9C : ICD-9-CM
International Classification of Diseases, 9th Clinical Modification.
The OID for this table is 2.16.840.1.113883.6.2.
42 IC10: ICD-10-CM
International Classification of Diseases, 10th Clinical Modification.
The OID for this table is 2.16.840.1.113883.x.x.
43 iso+: Extended ISO Units Codes
ISO 2955-1983 and extensions as defined in HL7 Version 2.4 Figure 7-9. Due to its length the table is included in the HL7 Additional Information Specification Implementation Guide rather than in this Additional Information Specification.
The OID for this table is 2.16.840.1.113883.6.2.
44 NDC: National Drug Code
The National Drug Code (NDC), administered by the FDA, provides a unique code for each distinct drug, dose form, manufacturer, and package. (Available from the National Drug Code Director, FDA, Rockville, MD, and other sources.)
The OID for this table is 2.16.840.1.113883.5.141.
45 RXNC: RxNorm SCD (Semantic Clinical Drug)
RxNorm, a standardized nomenclature for clinical drugs, is produced by the National Library of Medicine. In this context, a clinical drug is a pharmaceutical product given to (or taken by) a patient with a therapeutic or diagnostic intent. In RxNorm, the name of a clinical drug combines its ingredients, strengths, and form. RxNorm follows a standard format in the naming of clinical drugs. Drugs named in disparate ways in various other vocabularies are normalized according to RxNorm’s naming conventions. RxNorm SCD includes ingredient plus strength and dose form. (Example: Fluoxetine 4 MG/ML Oral Solution).
RxNorm can be obtained from the National Library of Medicine at: nlm..
The OID for this table is 2.16.840.1.113883.5.x.xxx.
46 RXNB: RxNorm SBD (Semantic Branded Drug)
RxNorm, a standardized nomenclature for clinical drugs, is produced by the National Library of Medicine. In this context, a clinical drug is a pharmaceutical product given to (or taken by) a patient with a therapeutic or diagnostic intent. In RxNorm, the name of a clinical drug combines its ingredients, strengths, and form. RxNorm follows a standard format in the naming of clinical drugs. Drugs named in disparate ways in various other vocabularies are normalized according to RxNorm’s naming conventions. RxNorm SBD includes ingredient, strength, and dose form plus brand name. ( Example: Fluoxetine 4 MG/ML Oral Solution [Prozac]).
RxNorm can be obtained from the National Library of Medicine at: nlm..
The OID for this table is 2.16.840.1.113883.x.xxx.
47 DEA: Drug Enforcement Administration
[Change this description to describe the DEA Number and where to get more information on the DEA Number. See NDC]
The US Drug Enforcement Administration is charged by statute the maintenance of controls against diversion of controlled substances and with the registration of all manufacturers and distributors of controlled substances and practitioners dispensing schedule III, IV or V drugs. The DEA number is assigned to practitioners meeting the criteria for dispensing, ordering and management of a patient on narcotic therapy.
Further information and Application for a DEA number may be obtained at
Special DEA: Drug Enforcement Administration
The US Drug Enforcement Administration is charged by statute the maintenance of controls against diversion of controlled substances and with the registration of all manufacturers and distributors of controlled substances and practitioners dispensing schedule III, IV or V drugs. The DEA number is assigned to practitioners meeting the criteria for dispensing, ordering and management of a patient on narcotic therapy. The Drug Addiction Treatment Act of 2000 (DATA2000) allows qualified physicians to practice medication-assisted opioid addiction therapy with specifically FDA-approved Schedule III, IV or V narcotic medications. The practitioner must submit a notice of intent to the Center for Substance Abuse Treatment (CSAT) a component of the Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services. Upon approval the DEA assigns a special identification number in addition to the practitioner’s regular DEA number.
To obtain further information contact and search waiver qualifications. Further information and Application for a DEA number may be obtained at .
The OID for this table is 2.16.840.1.113883.x.xxx.
48 HCI: HCIdea
HCIdea™ is an NCPDP prescriber identity management database solution designed to address the needs of organizations wishing to identify prescribers of drugs. An NCPDP HCIdea™ Prescriber Identity Layout is available upon request. For information about obtaining the NCPDP HCIdea™ file and the current (version 1.1) file format, please contact Robin Ebert at 480-477-1000, ext. 118 or rebert@
Contact Information
National Council of Prescription Drug Programs (NCPDP)
9240 East Raintree Drive
Scottsdale, AZ 85260
(480) 477-1000
(480) 767-1042 (fax)
The OID for this table is 2.16.840.1.113883.x.xxx.
49 NPI: National Provider Identifier
On January 23, 2004, the Secretary of HHS published a final rule (Federal Register volume 69, page 3434) which establishes the standard for a unique health identifier for health care providers for use in the health care system, and announces the adoption of the National Provider Identifier (NPI) as that standard. It also establishes the implementation specifications for obtaining and using the standard unique health identifier for health care providers.
For more information contact the US Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), 7500 Security Blvd., Baltimore, MD 21244
The DHHS Administrative Simplification web site is .
The OID for this table is 2.16.840.1.113883.4.6
50 PTX: Health Care Provider Taxonomy
The National Uniform Claim Committee (NUCC) maintains the Health Care Provider Taxonomy. The code set is available through Washington Publishing. See:
The OID for this table is 2.16.840.1.113883.6.101.
51 Miscellaneous OID References
This section contains a list of OID references used in the construct of the CDA header and body not otherwise noted in the above code set and table references.
1 Unique Instance Identifier
The OID 2.16.840.1.113883.3.933 is used to identify the “unique instance ID” for this document.
2 person_name.type_cd
OID 2.16.840.1.113883.12.200 is an object identifier for the person_name.type_cd component.
3 Proprietary Provider ID
OID 2.16.840.1.113883.12.200 is an object identifier for the person_name.type_cd component.
4 Example OID
In some instances in the example, OID 2.16.840.1.113883.19.7.xxx was used where xxx represents an author assigned number. This is used for demonstration purposes only. The actual OID for that concept will be included in the final published version of the document.
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[1] LOINC® is a registered trademark of Regenstrief Institute and the LOINC Committee. The LOINC database and LOINC Users’ Guide are copyright 1998-2005 Regenstrief Institute and the LOINC Committee and the LOINC database codes and names are available at no cost from . Regenstrief Institute, 1050 Wishard Blvd., Indianapolis, IN 46202 Email: LOINC@
[2]Information on this and other X12N/HIPAA-related implementation guides is available from the Washington Publishing Company, PMB 161, 5284 Randolph Rd., Rockville, MD 20852-2116. Phone: 800-972-4334. or
[3] Within this Health Level Seven document, references to the transaction defined by these X12N implementation guides will be abbreviated by calling them 275 and 277.
[4] Health Level Seven, Inc. 3300 Washtenaw Ave., Suite 227, Ann Arbor, MI 48104-4250. ()
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