USCDI Export for the Public
| Classification Level Sort descending | Data Class | Data Class Description | Data Element | Data Element Description | Applicable Standards | Submitter Name | Submitter Organization | Submission Date |
|---|---|---|---|---|---|---|---|---|
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administration Status | A code specifying the status of the Administration of a drug. This would clearly identify the current status of the drug administration. At any time, some codes may be ambiguous, such as “in-progress”, in that it is not currently clear if the administration process moved forward. Other codes will provide definitive states of the administration. For instance, “completed” shows the administration was completed, while “entered-on-error” indicates the prescription process was halted and the administration did not move forward | In FHIR R4, https://www.hl7.org/fhir/medicationadministration-definitions.html#MedicationAdministration.status |
Scott Gordon | Food and Drug Administration | |
| Level 0 | Work Information | Job Start Date | The date a person started working in a Job. | Nedra Garrett | CDC | |||
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Amount Paid by Patient | The amount paid by the member at the point of service. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Claim Operating Surgeon Name | The name of the operating surgeon. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Expanded list of clinical notes, detailed in Data Element Description | Audiometry/Audiology Audiograms: (68635-2 Audiology Diagnostic study note) Psychology Reports Mental Status Evaluation: (94798-6 Psychology Diagnostic study note) Neuropsychological Testing: (94798-6 Psychology Diagnostic study note) Psychological Testing: (94798-6 Psychology Diagnostic study note) Cardiac Reports Angiogram: (75425-9 Cardiology Diagnostic study note) Cardiac Catheterization: (75425-9 Cardiology Diagnostic study note) Doppler Test (75425-9 Cardiology Diagnostic study note) Electrocardiograph, electrocardiogram (EKG/ECG) result/interpretation: (75425-9 Cardiology Diagnostic study note) EKG/ECG Tracing Image: (75425-9 Cardiology Diagnostic study note) Echocardiogram result/interpretation: (75425-9 Cardiology Diagnostic study note) Stress Testing (exercise, pharma): (83539-7 Cardiology Risk assessment & screening note) Holter monitor: (83539-7 Cardiology Risk assessment & screening note) Neurology Electroencephalogram (EEG): (68556-0 Neurology Diagnostic study note) Electromyogram/nerve conduction (EMG): (68556-0 Neurology Diagnostic study note) Myelogram: (68556-0 Neurology Diagnostic study note) Ophthalmology/Optometry Visual Acuity: (78573-3 Ophthalmology Diagnostic study note) Visual Fields: (78573-3 Ophthalmology Diagnostic study note) Radiology (Interpretations Only; No Images) CT: (68604-8 Ophthalmology Diagnostic study note) MRI: (68604-8 Ophthalmology Diagnostic study note) PET: (68604-8 Ophthalmology Diagnostic study note) X-Ray: (68604-8 Ophthalmology Diagnostic study note) Respiratory DLCO Study: (80792-5 Pulmonary Diagnostic study note) Pulmonary Function Study: (80792-5 Pulmonary Diagnostic study note) Spirometry Test result/interpretation: (80792-5 Pulmonary Diagnostic study note) Spirometry Tracing Image: (80792-5 Pulmonary Diagnostic study note) Surgical Diagnostics Bone Marrow (Biopsy/Aspiration): (48807-2 Bone marrow aspiration report) Colonoscopy: (18746-8 Colonoscopy study report) Endoscopy: (18751-8 Endoscopy study report) Additional Procedures Ultrasound (exclude Doppler): (59282-4 Stress cardiac echo study report) Genetic Testing: (51969-4 Genetics analysis report) Physical Exam: (29545-1 Physical findings narrative) |
LOINC—although we would like to see the set of codes constrained as suggested above. In Data Element Description above, we have the suggested LOINC code (showing also the Long Common Name) for each Note in our list. Such constraints are needed in order to allow for semantic interoperability. |
KarenP-SSA | Social Security Administration (SSA) | |
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Clinical Notes for Newborn | Clinical notes information for a newborn may include the Labor and delivery summary record under–Infant data, and maternal progress note. Example information will include breastfeeding information at time of discharge. |
LOINC codes exist for each of the proposed data elements The clinical notes of an new born should capture information such as: 73756-9 | Infant is being breastfed at discharge |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | |
| Level 0 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Reason for the Encounter | Reason the encounter takes place, expressed as a code. |
Encounter Status: FHIR Encounter Status: http://hl7.org/fhir/ValueSet/encounter-status Classification of Encounter: V3 Value SetActEncounterCode: http://hl7.org/fhir/ValueSet/v3-ActEncounterCode Encounter Type: FHIR Encounter type: http://www.ama-assn.org/go/cpt Encounter participant type: FHIR Participant type: http://hl7.org/fhir/ValueSet/encounter-participant-type Reason for the encounter: FHIR Encounter Reason Codes: http://hl7.org/fhir/ValueSet/encounter-reason Hospital encounter discharge disposition: FHIR Discharge disposition: http://hl7.org/fhir/ValueSet/encounter-discharge-disposition Expected source(s) of payment for this encounter: FHIR Coverage Type and Self-Pay Codes: http://hl7.org/fhir/R4/valueset-coverage-type.html Encounter chief complaint: FHIR DiagnosisRole: http://hl7.org/fhir/R4/valueset-diagnosis-role.html |
Maria Michaels | CDC | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Claim Operating NPI | The identifier assigned to the Operating Surgeon. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Practitioner Identifier Type | Identifies the type of identifiers for practitioners |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Organization Identifier Type | Identifies the type of identifiers for organizations |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Newborn's Delivery Information | Pregnancy Outcome | The result of the subject’s delivery, such as live birth or not a live birth. |
LOINC codes exist for each of the proposed data elements: 73766-8: Place where birth occurred [US Standard Certificate of Live Birth] 8339-4 - Birth weight Measured |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| Level 0 | Newborn's Delivery Information | Birth Weight | The weight of the infant/fetus at birth/delivery. |
LOINC codes exist for each of the proposed data elements: 11884-4 - Gestational age Estimated 73766-8 - Place where birth occurred [US Standard Certificate of Live Birth] 64710-7 - Was your pregnancy a live birth, stillbirth, miscarriage, abortion, or ectopic pregnancy [PhenX] 8339-4 - Birth weight Measured 8305-5 - Body height --post partum 9272-6 - 1 minute Apgar Score 9274-2 - 5 minute Apgar Score 9271-8 - 10 minute Apgar Score |
TICIA Louise GERBER | Health Level Seven International | ||
| Level 0 | Pregnancy Information | Number of Prenatal Visits | The total number of prenatal visits for the mother. |
LOINC codes exist for each of the proposed data elements: 68493-6: Prenatal visits for this pregnancy # 69044-6: Date first prenatal visit 69461-2 Mother's body weight --at delivery 73772-6 The number of fetal deaths this delivery 73773-4 - Number of infants in this delivery delivered alive 57722-1 - Birth plurality of Pregnancy |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| Level 0 | Pregnancy Information | Mother’s Delivery Weight | The weight of the mother at the time of birth/delivery. |
LOINC codes exist for each of the proposed data elements: 68493-6: Prenatal visits for this pregnancy # 69044-6: Date first prenatal visit 69461-2 Mother's body weight --at delivery 73772-6 The number of fetal deaths this delivery 73773-4 - Number of infants in this delivery delivered alive 57722-1 - Birth plurality of Pregnancy |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| Level 0 | Pregnancy Information | Mother’s Prepregnancy Weight | The weight of the mother before becoming pregnant. |
LOINC codes exist for each of the proposed data elements: Last menstrual period start date: 8665-2 Delivery date Estimated: 11778-8 Body weight --pre current pregnancy: 56077-1 |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| Level 0 | Pregnancy Information | Plurality | The number of fetuses delivered live or dead at any time in the pregnancy regardless of gestational age, or if the fetuses were delivered at different dates in the pregnancy. (“Reabsorbed” fetuses, those which are not “delivered” (expulsed or extracted from the mother) should not be counted.) Include all live births and fetal losses resulting from this pregnancy. |
LOINC codes exist for each of the proposed data elements: 68493-6: Prenatal visits for this pregnancy # 69044-6: Date first prenatal visit 69461-2 Mother's body weight --at delivery 73772-6 The number of fetal deaths this delivery 73773-4 - Number of infants in this delivery delivered alive 57722-1 - Birth plurality of Pregnancy |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| 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 Total Submitted Amount | Amount submitted by the provider for reimbursement of health care services. This amount includes non-covered services. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Claim Total Allowed Amount | The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for non-contracted providers. Allowed amount should not include any COB adjustment. That is, the Allowed amount on a claim should be the same when the Plan is primary or secondary. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| 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. |
HHS Disability Status - Hearing | According to the HHS implementation guide there are six-item set of questions used on ACS and other major surveys to gauge disability is the data standard for survey questions on disability. (HHS Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status | ASPE). https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-disability-0 |
HL7 FHIR: US Public Health Disability Status HL7 CDA: Disability Status Observation VSAC Value Set: Disability Status (LOINC) |
Nedra Garrett | CDC | |
| 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. |
HHS Disability Status - Independence | According to the HHS implementation guide there are six-item set of questions used on ACS and other major surveys to gauge disability is the data standard for survey questions on disability. (HHS Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status | ASPE). https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-disability-0 The prompt for this data element should be consistent with HHS implementation guide: “Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?” |
HL7 FHIR: US Public Health Disability Status HL7 CDA: Disability Status Observation VSAC Value Set: Disability Status (LOINC) |
Nedra Garrett | CDC |