Multiple CPT E&M Codes

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 9/28/2017
  • SDWG: 11/30/2017

C-CDA 2.1 Example:

  • 2.16.840.1.113883.10.20.22.2.22:2015-08-01
  • 2.16.840.1.113883.10.20.22.2.22
  • 2.16.840.1.113883.10.20.22.4.49:2015-08-01
  • 2.16.840.1.113883.10.20.22.4.49
  • 2.16.840.1.113883.10.20.22.4.80:2015-08-01
  • 2.16.840.1.113883.10.20.22.4.80
  • 2.16.840.1.113883.10.20.22.4.4:2015-08-01
  • 2.16.840.1.113883.10.20.22.4.4

Reference to full CDA sample:

  • Encounter in empty CCD

Validation location

Comments

  • This is an example of how to record multiple CPT Evaluation and Management codes with a single encounter.

Custodian

  • Fred Harmon (Fred.Harmon@greenwayhealth.com)

Keywords

  • Encounter, E&M, CPT codes

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Links

 

Example: download example view on GitHub 

    <section>
        <templateId root="2.16.840.1.113883.10.20.22.2.22" assigningAuthorityName="CCDA Encounters Section" extension="2015-08-01" />
        <templateId root="2.16.840.1.113883.10.20.22.2.22" assigningAuthorityName="CCDA Encounters Section" />
        <id root="6c628dae-578b-4e3a-b0d9-e82453d29c14" />
        <code code="46240-8" displayName="History of encounters" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
        <title>Encounters</title>
        <text>
            <table width="100%">
                <thead>
                    <tr>
                        <th>Encounter</th>
                        <th>Provider</th>
                        <th>Location</th>
                        <th>Date</th>
                        <th>Diagnosis</th>
                    </tr>
                </thead>
                <tbody>
                    <tr ID="encounterDescriptionID0">
                        <td ID="encounterTypeDescriptionID0">Wellness Visit</td> 
                        <td>David E Ford MD</td>
                        <td>
                        </td>
                        <td>09/18/2017</td>
                        <td><content ID="encounterDiagnosisID0">Jaw Asymmetry Maxillary</content>, <content ID="encounterDiagnosisID1">Anomaly of Dental Arch</content>, <content ID="encounterDiagnosisID2">Malocclusion Mesio-occlusion</content></td>
                    </tr>
                </tbody> <!-- Some systems may include the CPT E&M code descriptions in the narrative -->
            </table>
        </text>
        <entry typeCode="DRIV">
            <encounter classCode="ENC" moodCode="EVN">
                <templateId root="2.16.840.1.113883.10.20.22.4.49" assigningAuthorityName="CCDA Encounter Activity" extension="2015-08-01" />
                <templateId root="2.16.840.1.113883.10.20.22.4.49" assigningAuthorityName="CCDA Encounter Activity" />
                <id root="2.16.840.1.113883.3.140.1.1918489287.6.10.16" extension="449" assigningAuthorityName="Intergy Encounter ID" />
                <id root="2.16.840.1.113883.3.140.1.1918489287.6.10.16.1" extension="271818" assigningAuthorityName="Intergy Encounter Number" />
                <code code="AMB" displayName="ambulatory" codeSystem="2.16.840.1.113883.1.11.13955" codeSystemName="ActEncounterCode">
                    <originalText>
                        <reference value="#encounterTypeDescriptionID0"/><!-- This is the text the user saw and was the basis for the AMB coding -->
                    </originalText>
                </code>
                <text>
                    <reference value="#encounterDescriptionID0" />
                </text>
                <effectiveTime>
                    <low value="20170918093900-0400" />
                    <high value="20170918095100-0400" /> 
                </effectiveTime>
                <!-- Could include optional performer -->
                <entryRelationship typeCode="COMP"> <!-- Encounter Diagnosis Act -->
                    <act classCode="ACT" moodCode="EVN">
                        <templateId root="2.16.840.1.113883.10.20.22.4.80" assigningAuthorityName="CCDA Encounter Diagnosis" extension="2015-08-01" />
                        <templateId root="2.16.840.1.113883.10.20.22.4.80" assigningAuthorityName="CCDA Encounter Diagnosis" />
                        <id root="2.16.840.1.113883.3.140.1.1918489287.6.10.7" extension="449" />
                        <code code="29308-4" displayName="Diagnosis" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
                        <entryRelationship typeCode="SUBJ" inversionInd="false">
                            <observation classCode="OBS" moodCode="EVN" negationInd="false">
                                <templateId root="2.16.840.1.113883.10.20.22.4.4" assigningAuthorityName="CCDA Problem Observation" extension="2015-08-01" />
                                <templateId root="2.16.840.1.113883.10.20.22.4.4" assigningAuthorityName="CCDA Problem Observation" />
                                <id root="755efd22-a0d1-4504-9e6f-de4e173f91bc" />
                                <code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
                                    <translation code="75326-9" displayName="Problem" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
                                </code>
                                <statusCode code="completed" />
                                <effectiveTime>
                                    <low value="20170918093900-0400" />
                                    <high nullFlavor="NI"/> <!-- Better to omit high if problem is ongoing, but if you always include high use nullFlavor=NI --> 
                                </effectiveTime>
                                <value code="235083001" displayName="Asymmetry of maxilla (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" xsi:type="CD">
                                    <originalText>
                                        <reference value="#encounterDiagnosisID0" />
                                    </originalText>
                                    <translation code="524.11" displayName="Jaw Asymmetry Maxillary" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD9CM" />
                                    <translation code="M26.11" displayName="Jaw Asymmetry Maxillary" codeSystem="2.16.840.1.113883.6.3" codeSystemName="ICD10" />
                                    <translation code="95980" displayName="Jaw Asymmetry Maxillary" codeSystem="2.16.840.1.113883.6.26" codeSystemName="MEDCIN" />
                                </value>
                            </observation>
                        </entryRelationship>
                        <entryRelationship typeCode="SUBJ" inversionInd="false">
                            <observation classCode="OBS" moodCode="EVN" negationInd="false">
                                <templateId root="2.16.840.1.113883.10.20.22.4.4" assigningAuthorityName="CCDA Problem Observation" extension="2015-08-01" />
                                <templateId root="2.16.840.1.113883.10.20.22.4.4" assigningAuthorityName="CCDA Problem Observation" />
                                <id root="c351f35e-ad79-4519-aae2-153526171926" />
                                <code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
                                    <translation code="75326-9" displayName="Problem" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
                                </code>
                                <statusCode code="completed" />
                                <effectiveTime>
                                    <low value="20170918093900-0400" />
                                    <high nullFlavor="NI"/> <!-- Better to omit high if problem is ongoing, but if you always include high use nullFlavor=NI -->
                                </effectiveTime>
                                <value code="23997001" displayName="Anomaly of dental arch (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" xsi:type="CD">
                                    <originalText>
                                        <reference value="#encounterDiagnosisID1" />
                                    </originalText>
                                    <translation code="524.20" displayName="Anomaly of Dental Arch" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD9CM" />
                                    <translation code="312141" displayName="Anomaly of Dental Arch" codeSystem="2.16.840.1.113883.6.26" codeSystemName="MEDCIN" />
                                </value>
                            </observation>
                        </entryRelationship>
                        <entryRelationship typeCode="SUBJ" inversionInd="false">
                            <observation classCode="OBS" moodCode="EVN" negationInd="false">
                                <templateId root="2.16.840.1.113883.10.20.22.4.4" assigningAuthorityName="CCDA Problem Observation" extension="2015-08-01" />
                                <templateId root="2.16.840.1.113883.10.20.22.4.4" assigningAuthorityName="CCDA Problem Observation" />
                                <id root="1dd3d744-6108-4284-823a-138c2568e446" />
                                <code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
                                    <translation code="75326-9" displayName="Problem" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
                                </code>
                                <statusCode code="completed" />
                                <effectiveTime>
                                    <low value="20170918093900-0400" />
                                    <high nullFlavor="NI"/> <!-- Better to omit high if problem is ongoing, but if you always include high use nullFlavor=NI -->
                                </effectiveTime>
                                <value code="12264001" displayName="Mesio-occlusion of teeth (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" xsi:type="CD">
                                    <originalText>
                                        <reference value="#encounterDiagnosisID2" />
                                    </originalText>
                                    <translation code="524.23" displayName="Malocclusion Mesio-occlusion" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD9CM" />
                                    <translation code="M26.213" displayName="Malocclusion Mesio-occlusion" codeSystem="2.16.840.1.113883.6.3" codeSystemName="ICD10" />
                                    <translation code="219237" displayName="Malocclusion Mesio-occlusion" codeSystem="2.16.840.1.113883.6.26" codeSystemName="MEDCIN" />
                                </value>
                            </observation>
                        </entryRelationship>
                    </act>
                </entryRelationship>
                <entryRelationship typeCode="REFR" inversionInd="false">
                    <act classCode="ACT" moodCode="EVN">
                        <code code="99408" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12" displayName="Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes" />
                    </act>
                </entryRelationship>
                <entryRelationship typeCode="REFR" inversionInd="false">
                    <act classCode="ACT" moodCode="EVN">
                        <code code="99394" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12" displayName="Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent"/>
                    </act>
                </entryRelationship>
                <entryRelationship typeCode="REFR" inversionInd="false">
                    <act classCode="ACT" moodCode="EVN">
                        <code code="99213" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12" displayName="Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter."/>
                    </act>
                </entryRelationship>
            </encounter>
        </entry>
    </section>

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