| LinkID | Text | Definition | Answer  | 
|---|
|   home-o2-questionnaireresponse |  |  | Questionnaire:Referred Questionnaire for QuestionnaireResponse | 
|    1 | Patient Information |  |  | 
|     1.1 | Last Name but Different This Time |  | Quinton | 
|     1.2 | First Name |  | Vlad | 
|     1.3 | Middle Initial |  | A, N | 
|     1.4 | Date Of Birth |  | 1956-12-01 | 
|     1.5 | Gender |  | AdministrativeGender male: Male | 
|     1.6 | Medicare ID |  | 10A3D58WH22 | 
|    2 | Provider who is performing face-to-face evaluation |  |  | 
|     2.1 | Last Name |  | Doe | 
|     2.2 | First Name |  | Jane | 
|     2.3 | Middle Initial |  | B | 
|     2.4 | NPI |  | 1122334455 | 
|     2.5 | Date of Face-To-Face Evaluation |  | 2019-07-18 | 
|     2.6 | Record |  | Mr. Saul Moki | 
|    3 | Coverage Requirements |  |  | 
|     3.1 | Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy) |  | SNOMED CT 313296004: Mild chronic obstructive pulmonary disease | 
|     3.2 | Arterial oxygen saturation (Patient on room air while at rest and awake when tested) |  | 95 mm[Hg] (Details: UCUM  codemm[Hg] = 'mm[Hg]') | 
|     3.3 | Arterial Partial Pressure of Oxygen (PO2) (Patient on room air while at rest and awake when tested) |  | 83 mm[Hg] (Details: UCUM  codemm[Hg] = 'mm[Hg]') | 
|     3.4 | Arterial oxygen saturation (Patient tested during exercise) |  | 95 mm[Hg] (Details: UCUM  codemm[Hg] = 'mm[Hg]') | 
|     3.5 | Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise) |  | 78 mm[Hg] (Details: UCUM  codemm[Hg] = 'mm[Hg]') | 
|     3.6 | Is there a documented improvement of hypoxemia during exercise with oxygen? |  | true | 
|    4 | Prescribed Use |  |  | 
|     4.1 | Start date |  | 2019-07-18 | 
|     4.2 | Length of need: (months) (99 = lifetime) |  | 99 | 
|     4.3 | Peak Flow Rate |  |  | 
|      4.3.1 | LPM |  | 2 | 
|      4.3.2 | oxygen % |  | 98 | 
|     4.4 | Average Flow Rate |  |  | 
|      4.4.1 | LPM |  | 2 | 
|      4.4.2 | oxygen % |  | 97 | 
|     4.5 | Frequency of use (choose all that apply) |  | At rest and awake | 
|    5 | Oxygen Supply Order Details |  |  | 
|     5.1 | Current Order Description |  | HCPCS E0424 - Stationary Compressed Gaseous Oxygen System, Rental | 
|     5.1b | Current Order Is For A Portable Device |  |  | 
|     5.2 | Type |  | example.org 122: Compressed Gas | 
|     5.3 | Means of oxygen delivery and accessories |  | example.org 134: Mask | 
| 
  Documentation for this format |