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 | 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 Processing Status | Claim processing status code |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Social Determinants of Health | Education Level | Highest level of education obtained. This is important for research and health care policy using social determinants of health (SDOH). Value should be as identified by patient. The AAPM Operational Ontology for Radiation Oncology ( https://aapmbdsc.azurewebsites.net) identified this element as high priority for routine collection. Reference for value set items selected was American Community Survey https://www.census.gov/data/tables/2020/demo/educational-attainment/cps… . Standard values identified are Elementary School High School Or GED College no degree Associates degree vocational Associates degree academic Bachelor's degree Master's degree Professional degree Doctorate degree |
American Community Survey |
Charles Mayo | University of Michigan | ||
| Level 0 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Requested Procedure Identifier | The Requested Procedure is the unit of work resulting in one Diagnostic Imaging Report (https://www.healthit.gov/isa/taxonomy/term/2471/uscdi-v3#uscdi-proposal-mode-uscdi-data-element-page-display) with associated codified and billable acts. One or more Requested Procedures may have to be performed to satisfy an Imaging Service Request. Add info for field below: The current USCDI v2 Data Element, Diagnostic Imaging Test does not convey the hierarchy established in Diagnostic Imaging. The Order/Imaging Service Request generates one or more Requested Procedures, which generates one or more Scheduled Procedure Steps. See Appendix A, Clarification of Accession Number and Requested Procedure ID of Volume 1 of the IHE Radiology Technical Framework and DICOM Section 7.3 Extension of the DICOM Model of the Real World. | LOINC/RSNA Radiology Playbook includes Diagnostic Imaging Procedure Codes and Descriptions. HL7 Standard for CDA® Release 2: Imaging Integration; Basic Imaging Reports in CDA and DICOM Release 1 references LOINC® Document Type Codes, SNOMED CT® Quantity Measurement Type Codes, as well as DICOM Code Systems. FHIR ImagingStudy references SNOMED CT Body Structures |
Brian Bialecki | American College of Radiology | |
| Level 0 | Procedures | Activity performed for or on a patient as part of the provision of care. |
Procedures Provenance | Procedure provenance defines if the procedure was self-reported by the patient during the visit or completed by the provider. |
Rachel Eager | New York eHealth Collaborative | ||
| Level 0 | Provenance | The metadata, or extra information about data, regarding who created the data and when it was created. |
Report Submission Date/Time | The date and time at which the EHR system sends the report. |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| 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 Frequency Code | UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The third digit identifies the frequency of the bill for a specific course of treatment or inpatient confinement. |
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 Service Classification Type Code | UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The second digit classifies the type of care (service classification) being billed. |
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 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 | |
| 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 | |
| Level 0 | Health Status Assessments | Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, or patient’s healthcare provider that could identify a need, problem, or condition. |
Physical Activity – Minutes/week | For an average week in the last 30 days, how many minutes per week did the patient engage in moderate to vigorous exercise (like walking fast, running, jogging, dancing, swimming, biking, or other activities that cause a light or heavy sweat)? |
The following LOINC codes correspond to components of the proposed measures: 89555-7 – Physical Activity – Days/Week 68516-4 – Physical Activity – Minutes/Day 82291-6 – Physical Activity – Muscle-Strengthening For the overall minutes/week measure, there is a standard LOINC code 89574-8 – Exercise Vital Sign that groups the Days/Week and Minutes/Day component, however it does not actually support capturing the calculated Minutes/Week component, even though the submitter of the code (Kaiser Permanente) makes regular use of the calculated value. HL7 will work with Kaiser and Regenstrief to either allow the existing ‘panel’ code to capture the calculated days/week measure or add an additional component that supports the calculation, making it easier to query for patients outside guideline without requiring client-side calculation. |
Laurie P. Whitsel | American Heart Association/Physical Activity Alliance | |
| Level 0 | Substance Use | Secondhand Smoke Exposure | Assessment of a patient’s exposure to smoke emitted from tobacco products used by others. |
Exposure to Second Hand Tobacco Smoke: SNOMED 16090371000119103 History of Exposure to Second Hand Tobacco Smoke: SNOMED 699009004 No Known Exposure to Second Hand Tobacco Smoke: SNOMMED 711563001 Second hand smoke exposure CPHS (Children’s preventive health services) LOINC: 39243-1 |
Nedra Y Garrett | CDC | ||
| 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 | |
| Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Myelogram | Narrative clinical assessment of the Myelogram results. |
Please see suggestions from attached Excel document |
Melissa Ayres | SSA | |
| 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 | |
| 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 | |
| Level 0 | Cancer Care | Mode of Diagnosis | The diagnosis specifies a patient’s concern/problem after a series of diagnostic tests and screening procedures by the healthcare provider. Beyond the encounter diagnosis (existing USCDI data element), the Encounter Information should include the mode of diagnosis. The key to cancer treatment is the type of tumor and the encounter data must include how the diagnosis was assessed as well as the critical features on pathology (including modern molecular tumor profiling). |
ICD-10 : https://www.cms.gov/Medicare/Coding/ICD10 |
Kevin Jung | University of California San Francisco Breast Care Center | ||
| 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 | |
| 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 | |
| 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 | |
| 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 Sub Type | High-level categorization of the claim. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners |
