Patient Cost Transparency Implementation Guide
2.0.0-ballot - STU 2 Ballot US

This page is part of the Da Vinci Patient Cost Transparency Implementation Guide (v2.0.0-ballot: STU 2 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions

: PCT-GFE-Professional-MRI - XML Representation

Page standards status: Informative

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<Claim xmlns="http://hl7.org/fhir">
  <id value="PCT-GFE-Professional-MRI"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-professional"/>
  </meta>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: Claim</b><a name="PCT-GFE-Professional-MRI"> </a><a name="hcPCT-GFE-Professional-MRI"> </a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource Claim &quot;PCT-GFE-Professional-MRI&quot; </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-gfe-professional.html">PCT Good Faith Estimate Professional</a></p></div><p><b>ProviderEventMethodology</b>: EEMM1022</p><blockquote><p><b>GFEServiceLinkingInfo</b></p><blockquote><p><b>url</b></p><code>linkingIdentifier</code></blockquote><p><b>value</b>: 223452-2342-2435-008001</p><blockquote><p><b>url</b></p><code>plannedPeriodOfService</code></blockquote><p><b>value</b>: 2021-10-31</p></blockquote><p><b>identifier</b>: Placer Identifier/GFEProviderAssignedID0002</p><p><b>status</b>: active</p><p><b>type</b>: Professional <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-claim-type.html">Claim Type Codes</a>#professional)</span></p><p><b>use</b>: predetermination</p><p><b>patient</b>: <a href="Patient-patient1001.html">Patient/patient1001</a> &quot; BETTERHALF&quot;</p><p><b>created</b>: 2021-10-05</p><p><b>insurer</b>: <a href="Organization-org1001.html">Organization/org1001</a> &quot;Umbrella Insurance Company&quot;</p><p><b>provider</b>: <a href="Practitioner-Submitter-Practitioner-1.html">Practitioner/Submitter-Practitioner-1</a> &quot; OLOGIST&quot;</p><p><b>priority</b>: Normal <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-processpriority.html">Process Priority Codes</a>#normal)</span></p><h3>Payees</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td></tr><tr><td style="display: none">*</td><td>Provider <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-payeetype.html">Payee Type Codes</a>#provider)</span></td></tr></table><p><b>referral</b>: <span>: Referral Number</span></p><h3>Diagnoses</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td><td><b>PackageCode</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>Unspecified focal traumatic brain injury <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-icd10CM.html">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#S06.30)</span></td><td>Principal Diagnosis <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-ex-diagnosistype.html">Example Diagnosis Type Codes</a>#principal)</span></td><td>Head trauma - concussion <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-ex-diagnosisrelatedgroup.html">Example Diagnosis Related Group Codes</a>#400)</span></td></tr></table><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>true</td><td><a href="Coverage-coverage1001.html">Coverage/coverage1001</a></td></tr></table><blockquote><p><b>item</b></p><p><b>Service Description</b>: Imaging</p><p><b>GFEBillingProviderLineItemCtrlNum</b>: GFEBillingProviderLineItemCtrlNum-0001</p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#70551)</span></p><p><b>modifier</b>: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#70551)</span></p><p><b>serviced</b>: 2021-10-31</p><p><b>location</b>: Inpatient Hospital <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-CMSPlaceofServiceCodes.html">CMS Place of Service Codes (POS)</a>#21)</span></p><p><b>quantity</b>: 1</p><h3>UnitPrices</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>200</td><td>USD</td></tr></table><h3>Nets</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>200</td><td>USD</td></tr></table></blockquote><h3>Totals</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>200</td><td>USD</td></tr></table></div>
  </text>
  <extension
             url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology">
    <valueString value="EEMM1022"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo">
    <extension url="linkingIdentifier">
      <valueString value="223452-2342-2435-008001"/>
    </extension>
    <extension url="plannedPeriodOfService">
      <valueDate value="2021-10-31"/>
    </extension>
  </extension>
  <identifier>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
        <code value="PLAC"/>
        <display value="Placer Identifier"/>
      </coding>
    </type>
    <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
    <value value="GFEProviderAssignedID0002"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="professional"/>
      <display value="Professional"/>
    </coding>
  </type>
  <use value="predetermination"/>
  <patient>🔗 
    <reference value="Patient/patient1001"/>
  </patient>
  <created value="2021-10-05"/>
  <insurer>🔗 
    <reference value="Organization/org1001"/>
  </insurer>
  <provider>🔗 
    <extension
               url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy">
      <valueCodeableConcept>
        <coding>
          <system value="http://nucc.org/provider-taxonomy"/>
          <code value="2085D0003X"/>
          <display value="Diagnostic Neuroimaging (Radiology) Physician"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <reference value="Practitioner/Submitter-Practitioner-1"/>
  </provider>
  <priority>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/processpriority"/>
      <code value="normal"/>
    </coding>
  </priority>
  <payee>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
        <code value="provider"/>
      </coding>
    </type>
  </payee>
  <referral>
    <extension
               url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber">
      <valueString value="REF12022002-122"/>
    </extension>
    <display value="Referral Number"/>
  </referral>
  <diagnosis>
    <sequence value="1"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-10-cm"/>
        <code value="S06.30"/>
        <display value="Unspecified focal traumatic brain injury"/>
      </coding>
    </diagnosisCodeableConcept>
    <type>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
        <code value="principal"/>
      </coding>
    </type>
    <packageCode>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup"/>
        <code value="400"/>
        <display value="Head trauma - concussion"/>
      </coding>
    </packageCode>
  </diagnosis>
  <insurance>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>🔗 
      <reference value="Coverage/coverage1001"/>
    </coverage>
  </insurance>
  <item>
    <extension
               url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription">
      <valueString value="Imaging"/>
    </extension>
    <extension
               url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum">
      <valueIdentifier>
        <value value="GFEBillingProviderLineItemCtrlNum-0001"/>
      </valueIdentifier>
    </extension>
    <sequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="70551"/>
        <display
                 value="Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"/>
      </coding>
    </productOrService>
    <modifier>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="70551"/>
        <display
                 value="Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"/>
      </coding>
    </modifier>
    <servicedDate value="2021-10-31"/>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
        <display value="Inpatient Hospital"/>
      </coding>
    </locationCodeableConcept>
    <quantity>
      <value value="1"/>
    </quantity>
    <unitPrice>
      <value value="200"/>
      <currency value="USD"/>
    </unitPrice>
    <net>
      <value value="200"/>
      <currency value="USD"/>
    </net>
  </item>
  <total>
    <value value="200"/>
    <currency value="USD"/>
  </total>
</Claim>