Common CQL Artifacts for FHIR (US-Based)
1.0.0 - Informative 1

Common CQL Artifacts for FHIR (US-Based) - Downloaded Version null See the Directory of published versions

## Questionnaire: Example Medical Necessity For Authorization Of Catheters Questionnaire (Experimental)

Official URL: http://hl7.org/fhir/us/cql/Questionnaire/MNACQuestionnaire | Version: 1.0.0
Standards status: Informative | Computable Name: MNACQuestionnaire
Copyright/Legal: This content is informed by the following source, used with permission: https://www.hca.wa.gov/assets/billers-and-providers/13-760.pdf

This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.

Structure

LinkID | Text | Cardinality | Type | Description & Constraints
--- | --- | --- | --- | ---
MNACQuestionnaire | This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form. |  | Questionnaire | http://hl7.org/fhir/us/cql/Questionnaire/MNACQuestionnaire#1.0.0
request-info | Request Information | 0..1 | group |
request-info|date-of-request | DATE OF REQUEST | 0..1 | date |
diagnosis-info | Diagnosis Information | 0..1 | group |
diagnosis-info|diagnosis | Diagnosis | 0..1 | string |
item-requested | Item Requested | 0..1 | group |
item-requested|item | Item requested | 0..1 | string |
uti-history | UTI History | 0..1 | group |
uti-history|uti-last-year | The patient has|had documented recurrent urinary tract infections while on a program of clean cathing, twice within a 12 month period prior to beginning sterile cathing | 0..1 | boolean |
uti-history|uti-dates | Dates of UTIs in the last year | 0..1 | string | Enable When: uti-history|uti-last-year =
uti-history|antibiotics-used | Antibiotics used for UTIs in the last year | 0..1 | string | Enable When: uti-history|uti-last-year =
symptoms-info | Symptoms Information | 0..1 | group |
symptoms-info|symptoms | Check those that apply to your patient | 0..* | choice | Options: 7 options
symptoms-info|fever-temperature | If fever, state temperature in degrees | 0..1 | decimal | Enable When: symptoms-info|symptoms =
catheterization-frequency | Catheterization Frequency | 0..1 | group |
catheterization-frequency|frequency | How many times per day does the patient catheterize? | 0..1 | choice | Options: 4 options
additional-comments | Additional Comments | 0..1 | group |
additional-comments|comments | Additional Comment | 0..1 | string |
physician-info | Physician Information | 0..1 | group |
physician-info|name | Physician's Name | 0..1 | string |
physician-info|mobile | Telephone | 0..1 | string |
physician-info|fax | FAX | 0..1 | string |
physician-info|signature | Physician's Signature | 0..1 | attachment |
physician-info|phone-referring | Referring Physician Telephone | 0..1 | string |
physician-info|date | Date | 0..1 | string |
Documentation for this format

Options Sets

Answer options for symptoms-info|symptoms

- http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#Fever ("Fever; state temperature in degree")
- http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#UrinaryUrgencyFrequency ("Change in urinary urgency, frequency, or incontinence")
- http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#AutonomicDysreflexia ("Appearance of new or increase in autonomic dysreflexia")
- http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#PhysicalSignsProstatitis ("Physical signs of prostatitis, epididymitis, orchitis")
- http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#Immunosuppressed ("The patient is immunosuppressed")
- http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#Pyuria ("Pyuria")
- http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#SystemicLeukocytosis ("Systemic leukocytosis")

Answer options for catheterization-frequency|frequency

- http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency#2-4Times ("2-4 times")
- http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency#4-6Times ("4-6 times")
- http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency#6-8Times ("6-8 times")
- http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency#8TimesOrMore ("8 times or more")