Da Vinci Payer Data Exchange
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This page is part of the Da Vinci Payer Data Exchange (v2.0.0: STU2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

US Core Encounter

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An example mapping of Health Plan data for Members to the US Core Encounter profile is shown below:

When populating the encounter resource period - if claim has period, populate period; if only a date, populate the end date in a period element.

Add warning text to alert the user that Claims consider the date of service to be the date when the service is completed therefore one generally cannot infer the start date of a diagnosis or the encounter to be the same as the service date of a line item.

The essential fields (Must Support or Cardinality greater than 0..*) to be provided in the US Core Encounter resource are:

R4 Element Name Cardinality Type
Encounter.identifier identifier 0..* Identifier
Encounter.identifier.system system 1..1 uri
Encounter.identifier.value value 1..1 string
Encounter.status status 1..1 code
Encounter.class class 1..1 Coding
Encounter.type type 1..* CodeableConcept
Encounter.subject subject 1..1 Reference(US Core Patient Profile)
Encounter.participant participant 0..* BackboneElement
Encounter.participant.type type 0..* CodeableConcept
Encounter.participant.period period 0..1 Period
Encounter.participant.individual individual 0..1 Reference(US Core Practitioner Profile)
Encounter.period period 0..1 Period
Encounter.reasonCode reasonCode 0..* CodeableConcept
Encounter.hospitalization hospitalization 0..1 BackboneElement
Encounter.hospitalization.dischargeDisposition dischargeDisposition 0..1 CodeableConcept
Encounter.location location 0..* BackboneElement
Encounter.location.location location 1..1 Reference(Location)

Table Definition

Fields that can be mapped from the CARIN Blue Button IG CPCDS File are included in the table below:

US Core Element Must Support Cardinality CARIN-BB Element CPCDS Element Mapping or Implementer Note
Encounter.identifier S 0..* ExplanationOfBenefit.identifier [{“35”:”Payer claim unique identifier”}]. Note: Assign Payer System URI for Unique Claim Id in Encounter.identifier.system. SetClaim Id in Encounter.identifier.value
Encounter.identifier.system S 1..1   Note: Assign Payer System URI for Unique Claim Id in Encounter.identifier.system. Set Claim Id in Encounter.identifier.value
Encounter.identifier.value S 1..1   Note: Assign Claim Id in Encounter.identifier.value
Encounter.status S 1..1 ExplanationOfBenefit.status [{“140”:”Claim processing status code
”}]
Encounter.statusHistory.period   1..1   [{“177, 178”:”Statement From Date
Statement Through Date
”}]
Encounter.class S 1..1   Note: Use ExplanationOfBenefit.type [institutional|oral|pharmacy|professional|vision] to map to ActCode [IMP|AMB|AMB|AMB]
Encounter.classHistory.period   1..1 ExplanationOfBenefit.item.serviced.servicedPeriod, ExplanationOfBenefit.item.serviced.servicedDate [{“18, 19”:”Member Admission Date
Member Discharge Date”}, {“90, 119”:”Service from date, Service to date”}]
Encounter.type S 1..* ExplanationOfBenefit.type HCPCS codes are contained within CPT Code System.
Encounter.subject S 1..1 ExplanationOfBenefit.patient [{“Ref (1), Ref (109)”:”Member id, Patient account number”}, {“Ref (191)”:”Unique Member ID”}, {“Ref (110)”:”Medical record number”}]
Encounter.participant.type S 0..* ExplanationOfBenefit.careTeam.role [{“165”:”Care Team Role”}]
Encounter.participant.period S 0..1   Note: Provide information if available
Encounter.participant.individual S 0..1 ExplanationOfBenefit.careTeam.provider [{“Ref (93, 96, 98, 99, 173)”:”Provider attending, PCP, operating,
referring and supervising NPIs”}, {“Ref (166, 169, 182, 171, 174)”:”Provider
attending, PCP, operating, referring and supervising names”},
{“Ref (94, 167)”:”Claim Billing Provider NPI,
Claim Billing Provider Name”}]
Encounter.period S 0..1 ExplanationOfBenefit.item.serviced.servicedPeriod, ExplanationOfBenefit.item.serviced.servicedDate [{“18, 19”:”Member Admission Date
Member Discharge Date”}, {“90, 119”:”Service from date, Service to date”}]
Encounter.length S 0..1   . Note: Provide information if available
Encounter.reasonCode S 0..*   . Note: Provide information if available
Encounter.diagnosis   0..* ExplanationOfBenefit.diagnosis.onAdmission [{“21, 22, 23, 30, 31”:”Diagnosis Code”}, {“28, 29”:”Present on admission”}]
Encounter.hospitalization S 0..1   . Note: Provide information if available
Encounter.hospitalization.dischargeDisposition S 0..1   Note: Provide information if available
Encounter.location S 0..* ExplanationOfBenefit.locationReference Note: Reference to location where Encounter took place
Encounter.location.location S 1..1   Note: Reference to location where Encounter took place

Table Definition

Example Encounter Resource

An example mapping of an Encounter resource is shown here:

{
  "resourceType" : "Encounter",
  "id" : "example-1",
  "meta" : {
    "lastUpdated" : "2017-05-26T11:56:57.250-04:00",
    "profile" : [
      "http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">
Generated Narrative
id: example-1
meta: 
status: finished
class: <span title=\"{http://terminology.hl7.org/CodeSystem/v3-ActCode AMB}\">ambulatory</span>
type: <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99201}\">Office Visit</span>
subject: <a href=\"Patient-example.html\">Generated Summary: id: example; Medical Record Number = 1032702 (USUAL); active; Amy V. Shaw , Amy V. Baxter ; ph: 555-555-5555(HOME), amy.shaw@example.com; gender: female; birthDate: 1987-02-20</a>
period: Nov 1, 2015, 10:00:14 PM --> Nov 1, 2015, 11:00:14 PM
</div>"
  },
  "status" : "finished",
  "class" : {
    "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
    "code" : "AMB",
    "display" : "ambulatory"
  },
  "type" : [
    {
      "coding" : [
        {
          "system" : "http://www.ama-assn.org/go/cpt",
          "code" : "99201"
        }
      ],
      "text" : "Office Visit"
    }
  ],
  "subject" : {
    "reference" : "Patient/example"
  },
  "period" : {
    "start" : "2015-11-01T17:00:14-05:00",
    "end" : "2015-11-01T18:00:14-05:00"
  }
}

Refer to the US Core Additional examples of the US Core R4 Implementation Guide for further examples of completed Encounter Profiles .

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