USCDI Export for the Public

Download CSV

Classification Level Sort descending	Data Class	Data Class Description	Data Element	Data Element Description	Applicable Standards	Submitter Name	Submitter Organization	Submission Date
Level 0	Explanation of Benefit	Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.	Claim Bill Facility Type Code	UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The first digit of the three-digit number denotes the type of facility.	NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.	Mark Roberts	Leavitt Partners	09/30/2021 - 22:05
Level 0	Explanation of Benefit	Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.	Claim Inpatient Admission Type Code	Priority of the admission. Information located on (UB04 Form Locator 14). For example, an admission type of elective indicates that the patient's condition permitted time for medical services to be scheduled.	NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.	Mark Roberts	Leavitt Partners	09/30/2021 - 22:05
Level 0	Laboratory	Analysis of clinical specimens to obtain information about the health of a patient.	Test Result Harmonization Status	Harmonization status indicates equivalency of results across platforms and vendors, ie, a harmonized test for a particular analyte and specimen yield results equivalent to other harmonized tests for that analyte and specimen. Harmonization is required for full clinical interoperability of test results. Results from harmonized tests may be interpreted and trended together, and may use the same calculation and decision support rules. Machine learning models may be trained and applied to data sets from different test platforms and vendors if the tests are harmonized. Tests that are not harmonized do not yield comparable results and should be interpreted and processed separately, not in aggregate with other tests. Incorrect assumption of harmonization status is a serious patient safety risk, and lack of harmonization information impedes public health interpretation of test results.	These proposed elements are a work in progress and the CAP urges that the vocabulary standards listed be considered for a future version of USCDI: Reference Range: The CAP proposes that the content of this data element follow the OBX-7 field from the HL7 2.5.1 standard. The CAP supports the use of the HL7 2.5.1 standard because the standard was designed to help laboratories comply with CLIA requirements. For numerical values, the CAP also proposes the Unified Code for Units of Measure (UCUM) standard. The CAP supports the use of the UCUM standard because it is well-established and because a common standard for units of measure will reduce errors related to translation of units of measure from one system to another. Name and Address of Laboratory Location: In lieu of a non-standard and inefficient textual description of a name and address, the CAP is proposing the use of the CLIA identification number as the data element content. All laboratories performing clinical testing have a CLIA identification number and are required to be able to report it, so the use of this number is not burdensome. The name and location of a laboratory can be determined quickly from the CLIA number using available online resources (for example, https://www.cdc.gov/clia/LabSearch.html). Condition & Disposition of Specimens: The CAP proposes the use of SNOMED CT for data element content. SNOMED CT is a relatively complete, well-curated, and actively-managed medical ontology that has excellent coverage of concepts appropriate for description of laboratory specimens, specimen sources, and conditions, and supports a rich array of hierarchical and other concept relationships. Test Result Harmonization Status: This is the first proposal of a harmonization status data element, and examples do not exist in other health data standards. Recently the ISO defined standard methods for harmonizing laboratory tests (see ISO 17511:2020 and 21151:2020). The CAP proposes development of a standard representation of these methods as content for this data element.	Han Tran	College of American Pathologists (CAP)	09/30/2022 - 20:15
Level 0	Explanation of Benefit	Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.	Claim Inpatient Source Admission Code	Identifies the place where the patient was identified as needing admission to a facility. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15).	NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.	Mark Roberts	Leavitt Partners	09/30/2021 - 22:05
Level 0	Explanation of Benefit	Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.	Claim Diagnosis Related Group Version	Version of the DRG codes assigned for inpatient facility claims. Claim diagnosis related group (DRG) code value. Name of the DRG grouper assigned; i.e., MS-DRG, AP-DRG or APR-DRG	NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.	Mark Roberts	Leavitt Partners	09/30/2021 - 22:05
Level 0	Explanation of Benefit	Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.	Claim Adjusted to Identifier	If the current claim has been adjusted; i.e., replaced by or merged to another claim number, this data element represents that new number.	NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.	Mark Roberts	Leavitt Partners	09/30/2021 - 22:05
Level 0	Explanation of Benefit	Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.	Claim Adjusted from Identifier	If the current claim represents a claim that has been adjusted and was given a prior claim number, this field represents the prior claim number	NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.	Mark Roberts	Leavitt Partners	09/30/2021 - 22:05
Level 0	Explanation of Benefit	Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.	Payer Claim Unique Identifier	Identifier assigned by a payer for a claim received from a provider or subscriber. It is not the same identifier as that assigned by a provider.	NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.	Mark Roberts	Leavitt Partners	09/30/2021 - 22:05
Level 0	Explanation of Benefit	Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.	Member Discharge Date	Date the beneficiary was discharged from the facility, or died. Matches the Statement Thru Date. When there is a discharge date, the Patient Discharge Status Code indicates the final disposition of the patient after discharge.	NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.	Mark Roberts	Leavitt Partners	09/30/2021 - 22:05
Level 0	Explanation of Benefit	Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.	Member Admission Date	The date corresponding with admission of the beneficiary to a facility and the onset of services. May precede the Statement From Date if this claim is for a beneficiary who has been continuously under care.	NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.	Mark Roberts	Leavitt Partners	09/30/2021 - 22:05
Level 0	Immunizations	Record of vaccine administration.	Patient Assertion of Vaccine Credentials	Whether or not the patient asserts they have verifiable vaccine credentials.	HL7 FHIR: Vaccine Credential Patient Assertion Observation profile HL7 CDA: Vaccine Credential Patient Assertion Observation LOINC: 11370-4 "Immunization status - Reported"	Nedra Garrett	CDC	09/30/2021 - 18:53
Level 0	Substance Use		Alcohol binge episodes per month	This data element comprises how many alcohol binge episodes an individual has per month	Most of the requested data elements are in LOINC, as per the codes below. We have requested the addition of the NIAAA Single-Item Screener and the diagnosis of Alcohol Use Disorder to LOINC. AUDIT-C : 72109-2 Ethanol in blood: 5640-8 Ever drink alcohol: 69721-9 Average daily alcohol intake: 74013-4 Alcohol binge episodes/month: 11286-2 Alcohol abuse or dependence: 74043-1 Alcohol help during pregnancy: 64718-0	Laura Kwako	National Institute on Alcohol Abuse and Alcoholism	10/22/2020 - 19:43
Level 0	Patient Demographics/Information	Data used to categorize individuals for identification, records matching, and other purposes.	Country of Nationality	The patient's country of nationality.	HL7 FHIR® Implementation Guide: Electronic Case Reporting (eCR) based on FHIR R4 HL7 CDA® R2 Implementation Guide: Public Health Case Report - the Electronic Initial Case Report (eICR) HL7 FHIR: Country of Nationality profile HL7 CDA: Country of Nationality template SNOMED: 186034007 \|Ethnicity / related nationality data (observable entity)\| https://www.hl7.org/implement/standards/product_brief.cfm?product_id=519 https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436	Sarah Gaunt		12/07/2021 - 21:20
Level 0	Procedures	Activity performed for or on a patient as part of the provision of care.	Procedure Sequence	A number to uniquely identify procedure entries.		Jenna Stern	Vizient	09/30/2022 - 20:29
Level 0	Cancer Care		Cancer Treatment Evaluation Basis of Disease Status	What measures were used in the determination of the disease status. The AAPM Operational Ontology for Radiation Oncology ( https://aapmbdsc.azurewebsites.net) noted a Delphi process to identify standard values recommended for classification. These were Physical exam PSA Plain film radiographs Bone scan Magnetic Resonance Imaging Computed Tomograph Biochemical marker (PSA) PET-CT (PSMA) PET-CT (F-18 fluciclovine) PET-CT (C-11 choline) In OORO for each instance record of a Cancer Patient Treatment Outcome, multiple values of Evaluation Basis of Disease Status can be selected e.g. PSA, MRI		Charles Mayo	University of Michigan	09/28/2022 - 20:48
Level 0	Clinical Notes	Narrative patient data relevant to the context identified by note types. Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.	Physical Exam	Narrative clinical assessment of the Physical Exam results.	Please see suggestions from attached Excel document	Melissa Ayres	SSA	09/30/2022 - 20:25
Level 0	Clinical Notes	Narrative patient data relevant to the context identified by note types. Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.	Genetic Testing	Narrative clinical assessment of the Genetic Testing results.	Please see suggestions from attached Excel document	Melissa Ayres	SSA	09/30/2022 - 20:25
Level 0	Health Status Assessments	Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s authorized representative, or patient’s healthcare provider that could identify a need, problem, or condition.	Mental Status Evaluation	Narrative clinical assessment of the Mental Status Evaluation.	Please see suggestions from attached Excel document	Melissa Ayres	SSA	09/30/2022 - 20:25
Level 0	Cancer Care		Cancer Treatment Site of Recurrence	If there is a recurrence, then list sites of recurrence . The AAPM Operational Ontology for Radiation Oncology ( https://aapmbdsc.azurewebsites.net) noted a Delphi process to identify standard values recommended for classification. These were Primary- None Primary - Prostate Primary - Seminal Vesicles Nodal-None Nodal-Pelvic Nodal-Aortic Nodal-Distant Distant-None Distant- CHAARTED-Low Volume Distant- CHAARTED-High Volume Metastatic-Bone Metastatic-Viscera In OORO for each instance record of a Cancer Patient Treatment Outcome, multiple values of Evaluation Site of Recurrence can be selected e.g. Primary- None,Nodal-Distant		Charles Mayo	University of Michigan	09/28/2022 - 20:48
Level 0	Cancer Care		Radiation Therapy Dose Objective Condition	Desired relationship of the Dose Objective to the Value Standard Values (List): = < <= > >= ALARA		Elizabeth Covington	University of Michigan	09/29/2022 - 12:55