Hospital Discharge Encounter with Billable Diagnoses

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Example metadata last updated 2017-08-06 10:15:50.745000 UTC

Approval Status: Approved

  • Approval Status: Approved
  • Example Task Force: 12/18/2014
  • SDWG: 2/12/2015
  • SDWG C-CDA R2.1 Upgrade: 12/1/2016

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Comments:

  • This is an example of a hospitalization with discharge diagnoses. Meaningful Use requires a place to document encounter diagnoses, and this example attempts to satisfy. This example aligns with QRDA suggestion for encounter diagnosis.

Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)

Full sample: Encounter in empty CCD

Example: download example view on GitHub

<section> 
	<!-- Created for discussion on SDWG CDA Example Task Force. -->
	<!-- This is an example of a hospitalization as may be shown in encounters section. -->
	<!-- This example demonstrates how billable diagnoses could be included, if they are available -->
	<templateId root="2.16.840.1.113883.10.20.22.2.22.1"/>
	<templateId root="2.16.840.1.113883.10.20.22.2.22.1" extension="2015-08-01"/>
	<id root="6bc0419f-0398-4a56-8642-7054cbef448c"/>
	<code code="46240-8" codeSystem="2.16.840.1.113883.6.1" displayName="Encounters" codeSystemName="LOINC"/>
	<title>Encounters</title>
	<text>
		<table>
			<thead>
				<tr>
					<th>Encounter Type</th>
					<th>Provider</th>
					<th>Primary Diagnosis</th>
					<th>Other Diagnoses</th>
					<th>Start Date</th>
					<th>End Date</th>
					<th>Location</th>
					<th>Discharge Disposition</th>
				</tr>
			</thead>
			<tbody>
				<tr ID="Encounter1">
					<td ID="Enc1_Type">Inpatient</td>
					<td>James Getwell, DO</td>
					<td ID="Enc1_Dx1">Congestive Heart Failure</td>
					<td>
						<content ID="Enc1_Dx2">Diabetes</content> 
					</td>
					<td>10/28/2014 12:22pm</td>
					<td>10/31/2014 3:04pm</td>
					<td>Good Day Hospital (878)378-0909 1002 Healthcare Dr., Portland, OR, 97005</td>
					<td>Nursing Home</td>
				</tr>
			</tbody>
		</table>
	</text>
	<entry>
		<encounter moodCode="EVN" classCode="ENC">
			<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
			<templateId root="2.16.840.1.113883.10.20.22.4.49" extension="2015-08-01"/>
			<id root="248b2c03-2013-e138-07d1-001A64958C30"/>
			<!-- CPT code should be used for ambulatory visits, but for a hosptialization, another codeSystem is more appropriate-->
			<code code="99238" displayName="Discharge day management services" codeSystem="2.16.840.1.113883.6.12">
				<originalText>
					<reference value="#Enc1_Type"/>
				</originalText>
				<translation code="IMP" codeSystem="2.16.840.1.113883.5.4" displayName="Inpatient" codeSystemName="Act Encounter Code - Act Code"/>
			</code>
			<text>
				<reference value="#Encounter1" />
			</text>
			<!-- for a hospitalization, the low and high effectiveTimes would logically be admission and discharge date/time. --> 
			<effectiveTime xsi:type="IVL_TS">
				<low value ="201410281222+0500" />
				<high value="201410311504+0500" /> 
			</effectiveTime>
			<!-- Note that sdtc extension is used to document dischargeDisposition in encounters -->
			<sdtc:dischargeDispositionCode code="04" displayName="Discharged/Transferred to a Facility that Provides Custodial or Supportive Care" 
				codeSystem="2.16.840.1.113883.6.301.5" codeSystemName="NUBC UB-04 FL17">
			</sdtc:dischargeDispositionCode>
			<performer typeCode="PRF">
				<time>
					<low value="201410281222+0500" />
					<high value="201410311504+0500" />
				</time>
				<assignedEntity classCode="ASSIGNED">
					<id root="2.16.840.1.113883.4.6" extension="12345679"/>
					<code code="200000000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="ProviderCodes" displayName="Allopathic &amp; Osteopathic Physicians" />
					<addr use="WP">
						<streetAddressLine>763 Horseshoe Rd</streetAddressLine>
						<city>Gotham</city>
						<state>OR</state>
						<postalCode>98764</postalCode>
					</addr>
					<telecom use="WP" value="tel:+1(814)788-8000"/>
					<assignedPerson classCode="PSN" determinerCode="INSTANCE">
						<name>
							<given>James</given>
							<family>Getwell</family>
							<suffix>DO</suffix>
						</name>
					</assignedPerson>
				</assignedEntity>
			</performer>
			<participant typeCode="LOC">
				<!-- Service Delivery Location Template -->
				<participantRole classCode="SDLOC">
					<templateId root="2.16.840.1.113883.10.20.22.4.32"/>
					<code code="1061-1" codeSystem="2.16.840.1.113883.6.259" codeSystemName="Healthcare Service Location" displayName="Inpatient medical ward" />
					<addr use="WP">
						<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
						<city>Portland</city>
						<state>OR</state>
						<postalCode>97005</postalCode>
					</addr>
					<telecom use="WP" value="tel:+1(878)378-0909"/>
					<playingEntity classCode="PLC" determinerCode="INSTANCE">
						<name>Good Day Hospital</name>
					</playingEntity>
				</participantRole>
			</participant>
			<entryRelationship typeCode="SUBJ">
				<!-- This is the primary diagnosis on the bill -->
				<!-- Hospital discharge diagnosis act -->
				<act moodCode="EVN" classCode="ACT">
					<templateId root="2.16.840.1.113883.10.20.22.4.33"/>
					<templateId root="2.16.840.1.113883.10.20.22.4.33" extension="2015-08-01"/>
					<id root="1d7ff347-9dce-44db-8f66-fc17d8dc4aca"/>
					<code code="11535-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Hospital Discharge Diagnosis"/>
					<statusCode code="active"/>
					<!-- This represents the time that the concern was authored. Since this is a hospital discharge diagnosis, this is when it was coded-->
					<effectiveTime xsi:type="IVL_TS">
						<low value="20141102145806+0500" />
					</effectiveTime>
					<entryRelationship typeCode="SUBJ" inversionInd="false">
						<!-- Problem Observation -->
						<observation classCode="OBS" moodCode="EVN">
							<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
							<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
							<id root="20cdd1a0-6136-4939-802f-edfebe9320bc"/>
							<!-- We'll use the type of diagnosis, since this is a coded diagnosis, not from problem list-->
							<code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="282291009" displayName="Diagnosis">
								<translation code="29308-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis"/>
							</code>
							<text>
								<reference value="#Enc1_Dx1" />
							</text>
							<statusCode code="completed" />
							<effectiveTime>
								<!-- This represents the date of biological onset. Since this is a coded diagnosis, this may not be documented.-->
								<low nullFlavor="UNK" />
							</effectiveTime>
							<!-- This denotes that the diagnosis is the principal diagnosis. There is generally only a single diagnosis for coded bill.-->
							<!-- This current modeling aligns with QRDA. Substantial discussion occurred on the task force regarding this method. --> 
							<!-- Additional comments on this approach should be included in comments on the QRDA Implementation Guide. We will revisit if QRDA changes their standard approach.  --> 
							<priorityCode code="63161005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Principal"/>
							<!-- This is a hospital discharge diagnosis, so the ICD-9 (or ICD-10) diagnosis is in translation. -->
							<!-- If a SNOMED is available for this, it could be included, but mapping back from ICD-9 may not always be possible. -->
							<value xsi:type="CD" nullFlavor="OTH">
								<originalText>
									<reference value="#Enc1_Dx1" />
								</originalText>
								<translation xsi:type="CD" code="428.0" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD-9" displayName="Congestive heart failure, unspecified" />
							</value>
							<author>
								<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
								<time value="20141031"/>
								<assignedAuthor>
									<id extension="99999999" root="2.16.840.1.113883.4.6"/>
									<code code="204C00000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Health Care Provider Taxonomy" displayName="Neuromusculoskeletal Medicine, Sports Medicine" />
									<telecom use="WP" value="tel:555-555-1002"/>
									<assignedPerson>
										<name>
											<given>Henry</given>
											<family>Seven</family>
										</name>
									</assignedPerson>
								</assignedAuthor>
							</author>
						</observation>
					</entryRelationship>
				</act>
			</entryRelationship>
			<entryRelationship typeCode="SUBJ">
				<!-- Hospital discharge diagnosis act -->
				<act moodCode="EVN" classCode="ACT">
					<templateId root="2.16.840.1.113883.10.20.22.4.33"/>
					<templateId root="2.16.840.1.113883.10.20.22.4.33" extension="2015-08-01"/>
					<id root="f07886ea-7879-478e-8155-5c2cce5cba6a"/>
					<code code="11535-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Hospital Discharge Diagnosis"/>
					<statusCode code="active"/>
					<!-- This represents the time that the concern was authored. Since this is a hospital discharge diagnosis, this is when it was coded-->
					<effectiveTime xsi:type="IVL_TS">
						<low value="20141102145806+0500" />
					</effectiveTime>
					<entryRelationship typeCode="SUBJ" inversionInd="false">
						<!-- Problem Observation -->
						<observation classCode="OBS" moodCode="EVN">
							<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
							<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
							<id root="5f9b714d-a6ec-4f8f-95ae-ea75e5a54bac"/>
							<!-- We'll use the type of diagnosis, since this is a coded diagnosis, not from problem list-->
							<code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="282291009" displayName="Diagnosis">
								<translation code="29308-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis"/>
							</code>
							<text>
								<reference value="#Enc1_Dx2" />
							</text>
							<statusCode code="completed" />
							<effectiveTime>
								<!-- This represents the date of biological onset. Since this is a coded diagnosis, this may not be documented.-->
								<low nullFlavor="UNK" />
							</effectiveTime>
							<!-- This denotes that the diagnosis is a secondary diagnosis. There may be multiple secondary diagnoses on coded bills.-->
							<!-- This current modeling aligns with QRDA. Substantial discussion occurred on the task force regarding this method. --> 
							<!-- Additional comments on this approach should be included in comments on the QRDA Implementation Guide. We will revisit if QRDA changes their standard approach.  --> 
							<priorityCode code="2603003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Secondary"/>
							<!-- This is a hospital discharge diagnosis, so the ICD-9 (or ICD-10) diagnosis is in translation. -->
							<!-- If a SNOMED is available for this, it could be included, but mapping back from ICD-9 may not always be possible. -->
							<value xsi:type="CD" nullFlavor="OTH">
								<originalText>
									<reference value="#Enc1_Dx2" />
								</originalText>
								<translation xsi:type="CD" code="250.00" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD-9" displayName="Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled" />
							</value>
							<author>
								<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
								<time value="20141031"/>
								<assignedAuthor>
									<id extension="99999999" root="2.16.840.1.113883.4.6"/>
									<code code="204C00000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Health Care Provider Taxonomy" displayName="Neuromusculoskeletal Medicine, Sports Medicine" />
									<telecom use="WP" value="tel:555-555-1002"/>
									<assignedPerson>
										<name>
											<given>Henry</given>
											<family>Seven</family>
										</name>
									</assignedPerson>
								</assignedAuthor>
							</author>
						</observation>
					</entryRelationship>
				</act>
			</entryRelationship>
		</encounter>
	</entry>
</section>
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