CPCDS Data Dictionary & Resource Mapping - PowerPoint Presentation

CPCDS Data Dictionary & Resource Mapping

Claim # HarmonizedCPCDS ElementMAP IDR4 ResourceProfile Element1Claim service start dateSee LineExplanationOfBenefit.billablePeriod.start2Claim service end dateSee LineExplanationOfBenefit.billablePeriod.end3Claim paid date107ExplanationOfBenefit.payment.date4Claim received date88ExplanationOfBenefit.supportingInfo.{category=“clmrecvddate”, timingDate}5Member admission date18[ExplanationOfBenefit], [ExplanationOfBenefit.supportingInfo.valueReference(Encounter)][.billablePeriod.start],[.period]6Member discharge date19[ExplanationOfBenefit], [ExplanationOfBenefit.supportingInfo.valueReference(Encounter)][.billablePeriod.end],[.period]7Patient account number109Patient.identifier8Medical record number110Patient.identifier9Claim unique identifier35ExplanationOfBenefit.identifier10Claim adjusted from identifier111ExplanationOfBenefit.related.{relationship=“prior”, reference}11Claim adjusted to identifier112ExplanationOfBenefit.related.{relationship=“replaced”, reference}12Claim diagnosis related group32 – assigned DRG version code33- assigned DRG value113 – DRG grouper nameExplanationOfBenefit.supportingInfo.{category=“ms-drg”, code} Non Payer Resource (TBD)

Claim # HarmonizedCPCDS ElementMapIDR4 ResourceProfile Element13Claim inpatient source admission code13[ExplanationOfBenefit], [ExplanationOfBenefit.supportingInfo.valueReference(Encounter)][.supportingInfo.{category=“admsrc”, code}], [.hospitalization.admitSource]14Claim inpatient admission type code14[ExplanationOfBenefit], [ExplanationOfBenefit.supportingInfo.valueReference(Encounter)][.supportingInfo.{category=“admtype”, code}], [.type]15Claim bill facility type code114ExplanationOfBenefit.supportingInfo.{category=“tob-typeoffacility”, code}16Claim service classification type code115ExplanationOfBenefit.supportingInfo.{category=“tob-billclassification”, code}17Claim frequency code116ExplanationOfBenefit.supportingInfo.{category=“tob-frequency”, code}18Claim processing status code140ExplanationOfBenefit.status19Claim type code16ExplanationOfBenefit.type20Patient discharge status code117[ExplanationOfBenefit], [ExplanationOfBenefit.supportingInfo.valueReference(Encounter)][.supportingInfo.{category=“discharge-status”, code}], [.hospitalization.dischargeDisposition]21Claim payment denial code92ExplanationOfBenefit.payment.adjustmentReason22Claim primary payer identifier141ExplanationOfBenefit.insurance.{focal=“false”, coverage(Coverage).{payor(Organization).identifier, order=1}}23Claim payee type code 120 ExplanationOfBenefit .payee.type Non Payer Resource (TBD)

Claim # HarmonizedCPCDS ElementMapIDR4 ResourceProfile Element24Claim payee 121ExplanationOfBenefit.payee.party25Claim payment status code91ExplanationOfBenefit.payment.type26Claim payer identifier2ExplanationOfBenefit.insurance.{focal=“true”, coverage(Coverage).{payor(Organization).identifier, order=1|2}}

Claim # HarmonizedCPCDS ElementMapIDR4 ResourceProfile ElementDrug1Days supply77[ExplanationOfBenefit], [ExplanationOfBenefit.supportingInfo.{category, valueReference(MedicationDispense1)}][.supportingInfo.{category=“dayssupply”, valueQuantity}], [.daysSupply]2RX service reference number35[ExplanationOfBenefit], [ExplanationOfBenefit.supportingInfo.{category, valueReference(MedicationDispense1)}][.identifier], [.identifier]3DAW product selection code79[ExplanationOfBenefit], [ExplanationOfBenefit.supportingInfo.{category, valueReference(MedicationDispense1)}][.supportingInfo.{category=“dawcode”, code}], [.substitution.{wasSubstituted, type, reason}]4Refill number137[ExplanationOfBenefit], [ExplanationOfBenefit.supportingInfo.{category, valueReference(MedicationDispense1)}][.supportingInfo.{category=“refillnum”, valueQuantity}], [.{type, quantity}]5Prescription origin code143ExplanationOfBenefit.supportingInfo.{category=“rxorigincode”, code}6Plan reported brand-generic code144[ExplanationOfBenefit], [ExplanationOfBenefit.supportingInfo.{category, valueReference(MedicationDispense1)}][.supportingInfo.{category=“brandgeneric”, code}], [.medicationReference(Medication3).isBrand ] 7 Amol-CMS? Pharmacy service type code34 ExplanationOfBenefit.supportingInfo .{category, valueReference (MedicationDispense 1)} use supporting info with values from PHRMCY_SRVC_TYPE_CD.authorizingPrescription(MedicationRequest2).dispenseRequest.performer(Organization).type8 Amol-CMS?Patient residence code152ExplanationOfBenefit.supportingInfo.{category, valueReference(MedicationDispense1)} use supporting info with values from PTNT_RSDNC_CD.destination(Location) 1 – http://hl7.org/fhir/us/phcp/StructureDefinition/PhCP-MedicationDispense2 – http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest3 – http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication Non Payer Resource (TBD)

Claim # HarmonizedCPCDS ElementMapIDR4 ResourceProfile ElementProvider1Claim billing provider NPI77ExplanationOfBenefit.provider(Organization).identifier2Claim billing provider network status35ExplanationOfBenefit.supportingInfo.{category=“billingnetworkcontractingstatus”, code}3Claim attending provider NPI79ExplanationOfBenefit.careTeam.{sequence, provider(PractitionerRole).identifier, responsible=“true”, role=“supervising”}4Claim attending provider network status137ExplanationOfBenefit.supportingInfo.{category=“attendingnetworkcontractingstatus”, code}5Claim site of service NPI97ExplanationOfBenefit.facility(Location).identifier6Claim site of service network status101ExplanationOfBenefit.supportingInfo.{category=“sitenetworkcontractingstatus”, code}7Claim referring provider NPI99ExplanationOfBenefit.careTeam.{sequence, provider(PractitionerRole).identifier, role=“referrer”}8Claim referring provider network status105ExplanationOfBenefit.supportingInfo.{category=“referringnetworkcontractingstatus”, code}9Claim performing provider NPI95ExplanationOfBenefit.careTeam.{sequence, provider(PractitionerRole).identifier, role=“performing”}10Claim performing provider network status101ExplanationOfBenefit.supportingInfo.{category=“performingnetworkcontractingstatus”, code}

Claim # HarmonizedCPCDS ElementMapIDR4 ResourceProfile ElementProvider11Claim prescribing provider NPI122ExplanationOfBenefit.careTeam.{sequence, provider(PractitionerRole).identifier, role=“prescribing”}12Claim prescribing provider network status123ExplanationOfBenefit.supportingInfo.{category=“prescribingnetworkcontractingstatus”, code}13Claim PCP NPI96ExplanationOfBenefit.careTeam.{sequence, provider(PractitionerRole).identifier, role=“pcp”}

Claim # HarmonizedCPCDS ElementR4 ResourceProfile ElementAmounts1Claim total submitted amount20ExplanationOfBenefit.total.{category=“submitted”}2Claim total allowed amount20ExplanationOfBenefit. total.{category=“eligible allowed”}3Amount paid by patient20ExplanationOfBenefit.total.{category=“paidbypatient”}4Claim amount paid to provider20ExplanationOfBenefit.total.{category=“paidtoprovider”}5Member reimbursement20ExplanationOfBenefit.total.{category=“paidtopatient”}6Claim payment amount20ExplanationOfBenefit.total.{category=“benefit payment”}7Claim disallowed amount20ExplanationOfBenefit .total.{category=“noncovered disallowed”}8Member paid deductible20ExplanationOfBenefit.total.{category=“deductible”}9Co-insurance liability amount20ExplanationOfBenefit.total.{category=“coins”}10Copay amount20ExplanationOfBenefit.total.{category=“copay”}11Member liability 20 ExplanationOfBenefit . total.{category=“patientmember liability ”} 12 Claim primary payer paid amount 20ExplanationOfBenefit. adjudication.{category=“priorpayerbenefitpaid”}13Claim discount amount20ExplanationOfBenefit.total.{category=“discount”}

Claim Line # HarmonizedCPCDS ElementR4 ResourceProfile ElementLine Service Details1Service (from) date90, 118ExplanationOfBenefit.item.servicedDate OR .item.servicedPeriod2Line number36ExplanationOfBenefit.item.sequence3Service to date119ExplanationOfBenefit.item.servicedPeriod4Type of service34ExplanationOfBenefit.item.category5Place of service code46ExplanationOfBenefit.item.locationReference(Location).type6Revenue center code86ExplanationOfBenefit.item.revenue7Number of units42ExplanationOfBenefit.item.quantity8Allowed number of units149ExplanationOfBenefit.item.adjudication.{category=“units-allowed”, value}9National drug code38ExplanationOfBenefit.item.productOrService OR .item.detail. productOrService10Compound code78ExplanationOfBenefit.item.productOrService11Quantity dispensed39ExplanationOfBenefit.item.detail.quantity 12Quantity qualifier code151ExplanationOfBenefitItem.quantity.code or . item.quanity.unit . item.detail.quantity.code or .item.detail.quanity.unit 13 Line benefit payment status 142 ExplanationOfBenefit .item.adjudication.{category=“inoutnetwork”, reason}14Line claim payment denial code92ExplanationOfBenefit.item.adjudication.{category=“denialreason”, reason}

Claim Line # HarmonizedCPCDS ElementMapIDR4 ResourceProfile ElementLine Amount Details1Line disallowed amount20ExplanationOfBenefit.item.adjudication.{category=“noncovered disallowed”}2Line member reimbursement20ExplanationOfBenefit.item.adjudication.{category=“paidtopatient”}3Line amount paid by patient20ExplanationOfBenefit.item.adjudication.{category=“paidbypatient”}4Drug cost20ExplanationOfBenefit.item.net item.adjudication.{category=“drugcost”}5Line allowed payment amount20ExplanationOfBenefit.item.adjudication.{category=“benefit paymet”}6Line amount paid to provider20ExplanationOfBenefit.item.adjudication.{category=“paidtoprovider”}7Line patient deductible20ExplanationOfBenefit.item.adjudication.{category=“deductible”}8Line primary payer paid amount20ExplanationOfBenefit.item.adjudication.{category=“priorpayerbenefitpaid”}9Line coinsurance amount20ExplanationOfBenefit . item.adjudication .{category=“coins”}10Line submitted amount 20 ExplanationOfBenefit . item.adjudication .{category=“submitted”}11Line allowed amount20ExplanationOfBenefit.item.adjudication.{category=“eligible allowed”}12Line member liability20 ExplanationOfBenefit.item.adjudication.{category=“patientmember”}13 Line copay amount 20 ExplanationOfBenefit . item.adjudication .{category=“copay”} 14 Line discount ed amount 20 ExplanationOfBenefit . item.adjudication .{category=“discount ed ”}

Diagnoses # HarmonizedCPCDS ElementMapIDR4 ResourceProfile ElementDiagnosis (0-n)1Diagnosis code6, 7, 8, 21, 22, 23ExplanationOfBenefit.diagnosis.diagnosisCodeableConcept.coding.code2Diagnosis description145ExplanationOfBenefit.diagnosis.diagnosisCodeableConcept.coding.display3Present on admission28, 29ExplanationOfBenefit.diagnosis.onAdmission4Diagnosis code type6, 7, 8, 21, 22, 23ExplanationOfBenefit.diagnosis.diagnosisCodeableConcept.coding.system5Diagnosis type6, 7, 8, 21, 22, 23ExplanationOfBenefit .diagnosis.type={“primary”, “secondary”}6Is E code30ExplanationOfBenefit.diagnosis.type={“extcausecode”}

Procedures # HarmonizedCPCDS ElementMapIDR4 ResourceProfile ElementProcedure (0-n)1Procedure codeFAC IP – ICD PCS: 9, 11, 24, 26FAC OP, Professional and Other – CPT / HCPCS: 40ExplanationOfBenefit.procedure.procedureCodeableConcept. coding.code2Procedure descriptionICD procedure 146CPT4 / HCPCS procedure 147ExplanationOfBenefit.procedure.procedureCodeableConcept.text3Procedure dateFAC IP – ICD: 9, 11, 24, 26ExplanationOfBenefit.procedure.date4Procedure code typeFAC IP – ICD : 9, 11, 24, 26ExplanationOfBenefit.procedure.procedureCodeableConcept. coding.system5Procedure typeFAC IP - ICD: 9, 11, 24, 26ExplanationOfBenefit.procedure.type6Modifier Code -141ExplanationOfBenefit.item.modifier7Modifier Code -241ExplanationOfBenefit.item.modifier8Modifier Code -341ExplanationOfBenefit.item.modifier9Modifier Code -441ExplanationOfBenefit.item.modifier

Member # HarmonizedCPCDS ElementMapIDR4 ResourceProfile Element1Member id1EOB.patient(Patient)EOB.insurance.coverage(Coverage).beneficiary(Patient).identifier.identifier2Date of birth70Patient.birthDate33aDate of deathDeceased flag124Patient.deceasedDateTime4County125Patient.address5State126Patient.address6Country127Patient.address7Race code128Patient.extension (http://hl7.org/fhir/us/core/StructureDefinition/us-core-race)8Ethnicity129Patient.extension (http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity)9aBirth sex1539Gender code71Patient.gender10Name130Patient.name11Zip code131Patient.address12Relationship to subscriber72Patient?13 LisaSubscriber id132Patient.identifier

Coverage # HarmonizedCPCDS ElementMapIDR4 ResourceProfile Element1 LisaSubscriber id132Coverage.subscriberId2Coverage type3Coverage.type3Coverage status133Coverage.status4Start date74Coverage.period5End date75Coverage.period6Group id134Coverage.class7Group name135Coverage.class8PlanWhat is the definition of Plan- I.e., benefit Plan?Coverage.class9Payer IdentifierPayer Primary Identifier2140Coverage.payor

Terminology Bindings

ExplanationOfBenefit (Elements) #R4 Profile ElementCode SystemNotes, [CMS Medicare BB 2.0/ResDAC]1.related.relationshiphttp://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationshipExample2.statushttp://hl7.org/fhir/explanationofbenefit-statusRequired3.typehttp://terminology.hl7.org/CodeSystem/claim-typeExtensible5.diagnosis.typehttp://terminology.hl7.org/CodeSystem/ex-diagnosistypeExample6.supportingInfo.categoryhttp://terminology.hl7.org/CodeSystem/claiminformationcategoryExample7.supportingInfo.codehttp://example.org/fhir/CodeSystem/ms-drg (version=36),http://example.org/fhir/CodeSystem/typeofbill-facility-type (version=2007-03-01),http://example.org/fhir/CodeSystem/typeofbill-serviceclassification-type (version=2007-03-01),http://example.org/fhir/CodeSystem/typeofbill-frequency (version=2007-03-01)Required,[https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/MS-DRG-Classifications-and-Software.html version=36],[https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS1196256.html version=2007-03-01] UB-04 Type of Bill (FL-4)

ExplanationOfBenefit (Code Systems) #CodeDisplayDefinitionhttp://terminology.hl7.org/CodeSystem/claim-type (version=4.0.1)1inpatient-facilityClaims generated for clinics, hospitals, skilled nursing facilities, and other institutions for inpatient services, including the use of equipment and supplies, laboratory services, radiology services, and other charges (CMS-1450/UB-04 or 837-I).2outpatient-facilityClaims generated for clinics, hospitals, skilled nursing facilities, and other institutions for outpatient services, including the use of equipment and supplies, laboratory services, radiology services, and other charges (CMS-1450/UB-04 or 837-I).3professional-nonclinicianProfessional or Non-clinicianClaims generated for physicians, suppliers, and other non-institutional providers for both outpatient and inpatient services (CMS-1500 or 837-P) or claims with Level II HCPCS codes representing non-physician services like ambulance rides, wheelchairs, walkers, other durable medical equipment, and other medical services that are not identified by CPT-4/HCPCS Level I codes.4pharmacyPharmacyPharmacy claims for goods and services.5visionVisionVision claims for professional services and products such as glasses and contact lenses.6oralOralDental, Denture and Hygiene claims.

ExplanationOfBenefit (Code Systems) #CodeDisplayDefinitionhttp://terminology.hl7.org/CodeSystem/claiminformationcategory (version=4.0.1)cms-drgCMS DRGsCMS DRGs1ms-drgMedicare Severity DRGsMedicare Severity DRGsr-drgRefined DRGsRefined DRGsap-drgAll Patient DRGsAll Patient DRGss-drgSeverity DRGsSeverity DRGsaps-drgAll Patient, Severity-Adjusted DRGsAll Patient, Severity-Adjusted DRGsapr-drgAll Patient Refined DRGsAll Patient Refined DRGsir-drgInternational-Refined DRGsInternational-Refined DRGs2clmrecvddateClaim Received DateClaim received date3admsrcSource of AdmissionSource of Admission4admtypeType of Admission/VisitType of Admission/Visit5tob-typeoffacilityType of Bill – Type of facilityThe first character from the three-digit code located on the CMS 1450/UB-04 claim form (FL-4) that describes the type of bill a provider is submitting to a payer10tob-billclassificationType of Bill – Type of service provided to the beneficiaryThe second character from the three-digit code located on the CMS 1450/UB-04 claim form (FL-4) that describes the type of bill a provider is submitting to a payer11tob-frequencyType of Bill – FrequencyThe third character (i.e. sequence in this episode of care) from the three-digit code located on the CMS 1450/UB-04 claim form (FL-4) that describes the type of bill a provider is submitting to a payerdischarge-statusPatient Discharge StatusThe patient’s status as of the “Through” date of the billing periodbillingnetworkcontractingstatusBilling Provider Network StatusBilling Provider Network Statusattendingnetworkcontractingstatusreferringnetworkcontractingstatus sitenetworkcontractingstatus referring networkcontractingstatus performing networkcontractingstatus prescribing networkcontractingstatus 12prescription-informationPrescription informationPrescription information

ExplanationOfBenefit (Code Systems) #CodeDisplayDefinitionhttp://example.org/fhir/CodeSystem/rx-origin-code (version=4.0.1)10Not SpecifiedNot Specified21WrittenWritten32TelephoneTelephone43ElectronicElectronic54FacsimileFacsimile65PharmacyPharmacy

Encounter (Elements) # R4 Profile ElementCode SystemNotes, [CMS Medicare BB 2.0/ResDAC]1.hospitalization.admitSource.coding.codehttp://terminology.hl7.org/CodeSystem/admit-sourcePreferred, [https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS1196256.html, version=2007-03-01] UB-04 Source of Admission code (FL-15)2.type.coding.codehttp://terminology.hl7.org/CodeSystem/encounter-typeExample, [https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS1196256.html, version=2007-03-01] UB-04 Type of Admission/Visit (FL-14)3.hospitalization.dischargeDisposition.coding.codehttp://terminology.hl7.org/CodeSystem/discharge-dispositionExample,[https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS1196256.html, version=2007-03-01] UB-04 Patient Status (FL-17)

Encounter (Code Systems) # CodeDisplayDefinitionhttp://example.org/fhir/CodeSystem/typeofbill-facility-type (version=2007-03-01)

MedicationDispense # R4 Profile ElementCode SystemNotes, [CMS Medicare BB 2.0/ResDAC]1.substitution.type.coding.codehttp://hl7.org/fhir/v3/substanceAdminSubstitutionExample2.substitution.reason.coding.codehttp://hl7.org/fhir/v3/ActReasonExample3.type.coding.codehttp://hl7.org/fhir/v3/ActCodeExample

Location # R4 Profile ElementCode SystemNotes, [CMS Medicare BB 2.0/ResDAC]1.type.coding.codehttp://terminology.hl7.org/CodeSystem/v3-RoleCodeExtensible, [https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd/]

@ rryanhowells | ryan.howells@leavittpartners.com @carinalliance | www.carinalliance.com

Appendix

Health Plan Claims Extracts Health Plans send Claims data to their vendors and business associates under several use cases (care coordination, utilization management, predictive analytics) using a variety of custom, one-off, flat file extracts. No industry wide standard exists for Health Plans to send (adjudicated) Claims data to either Covered or Non-covered Entities.EDI X12 standards for Claims only exist for Providers’ HIPAA-covered transactions with Health Plans (i.e. Claim Submission – 837, Claim Acknowledgement – 277CA, and Payment/Remittance Advice – 835)Most Health Plans generate the flat file Claims extracts from their Claims System of Record (SOR) i.e. Claims Adjudication System, using mature, enterprise grade Extract, Transform and Load (ETL) tools and processes.

Provider B CARIN Blue Button Framework FHIR ServerHealth Plan ACARIN Blue Button IG (FHIR Profiles)EDI X12 and CPCDSCovered Entities/BAsHealth Plan BClaims SOR1 (EOB)Facets v4 (EOB)CPCDSHealth Plan CFacets v3 (EOB)Claims SOR2 (EOB)Data Hub AMulti-plan Data Warehouse (EOB)Health Plan DClaims SOR3 (EOB)837-I/CMS1450/UB04999277CA835Provider A270271EDI Clearinghouse837-P/CMS1500Key835 Electronic Remittance AdviceMappingsSOR System of RecordEDI X12 TransactionsCovered Entity/BA270 Eligibility & Benefits Inquiry277CA Individual Claim Acknowledgement999 Claims Submission Acknowledgement270 Eligibility & Benefits Response837 Claims Submission

CARIN BB IG Proposed EOB Profile Options CPCDS Inpatient Facility EOBOutpatient FacilityProfessional/Non-ClinicianPharmacyVisionOralComprehensive/GenericCPCDSInpatient FacilityOutpatient FacilityProfessional/Non-ClinicianPharmacyVisionOralComprehensive/GenericOption 1Option 2