Da Vinci Payer Data Exchange
2.0.0 - STU2 United States of America flag

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 Procedure

Previous Page - PDex Prior Authorization

The US Core Procedure profile SHALL be used to record a member’s health events.

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

R4 Element Name Cardinality Type
Procedure.status status 1..1 code
Procedure.code code 1..1 CodeableConcept
Procedure.subject subject 1..1 Reference(US Core Patient Profile)
Procedure.performed[x] performed[x] 1..1  

Table Definition

Health Plan Mapping Assistance

A collaboration of Health Plan experts has performed an evaluation of claims information and developed a mapping of data for Members to the US Core Procedure profile. This is shown below as an assistance to implementers:

US Core Element Must Support Cardinality CARIN-BB Element CPCDS Element Mapping or Implementer Note
Procedure.meta.lastUpdated   0..1 ExplanationOfBenefit.meta.lastUpdated [{“163”:”EOB Last Updated Date”}]
Procedure.identifier   0..* ExplanationOfBenefit.identifier + ExplanationOfBenefit.item.id [{“35”:”Payer claim unique identifier”}]. Note: Assign Payer System URI for Unique Claim Id in Procedure.identifier.system. Set Claim Id in Procedure.identifier.value. Add line item.id from EOB to identify multiple procedures on an EOB
Procedure.status S 1..1   Note: Note: EOB Status 0f [active | cancelled | draft | entered-in-error] = [completed|not-done|unknown|entered-in-error]
Procedure.code S 1..1 ExplanationOfBenefit.procedure.procedure [{“24, 26, 146”:”ICD Procedure Code”}, {“40”:”Procedure Code - CPT / HCPCS”}, {“41”:”Procedure Code Modifier - CPT / HCPCS”}]
Procedure.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”}]
Procedure.performed[x] S 1..1   Note: Enter Procedure.performedPeriod or Procedure.performedDateTime (next field below)
Procedure.performedDateTime     ExplanationOfBenefit.procedure.date, ExplanationOfBenefit.item.serviced.servicedPeriod, ExplanationOfBenefit.item.serviced.servicedDate [{“25, 27”:”Procedure date”}, {“90, 119”:”Service from date, Service to date”}]
Procedure.performedPeriod     ExplanationOfBenefit.procedure.date, ExplanationOfBenefit.item.serviced.servicedPeriod, ExplanationOfBenefit.item.serviced.servicedDate [{“25, 27”:”Procedure date”}, {“90, 119”:”Service from date, Service to date”}]
Procedure.location   0..1 ExplanationOfBenefit.item.location. locationCodeableConcept, ExplanationOfBenefit.item.supportingInfo.location. locationCodeableConcept [{“46”:”Place of service code”}, {“97, 170, 176”:”Service Facility NPI (if available), Name, Address”}]
Procedure.reasonCode   0..* ExplanationOfBenefit.diagnosis.diagnosis [{“22, 23”:”Diagnosis Code”}]

Table Definition

Note: Procedure records should only be created from ExplanationOfBenefit or CPCDS resources for items that are clinical procedures. Medications, facility charges and supplies should not be created as prodcudure records.

Example Procedure Resource

An example mapping of a Procedure resource for a medical implant is presented below:

{
  "resourceType" : "Procedure",
  "id" : "defib-implant",
  "meta" : {
    "profile" : [
      "http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">
Generated Narrative with Details
id: defib-implant
meta: 
identifier: urn:uuid:b2a737f2-2fdb-49c1-b097-dac173d07aff
status: completed
code: Insertion or replacement of permanent implantable defibrillator system with transvenous lead(s), single or dual chamber <span style=\"background: LightGoldenRodYellow\">(Details : {http://www.ama-assn.org/go/cpt code '33249' = '33249)</span>
subject: <a href=\"Patient-example.html\">Generated Summary: id: example; Medical Record Number = 1032702 (USUAL); active; Amy V. Shaw ; ph: 555-555-5555(HOME), amy.shaw@example.com; gender: female; birthDate: Feb 20, 2007</a>
performed: Mar 26, 2019, 7:55:26 PM --> Mar 26, 2019, 8:25:26 PM
Performers
<table class=\"grid\">-Actor*<a href=\"Practitioner-practitioner-1.html\">Generated Summary: id: practitioner-1; 9941339108, 25456; Ronald Bone </a></table>
FocalDevices
<table class=\"grid\">-Manipulated*<a href=\"Device-udi-2.html\">Generated Summary: id: udi-2; status: active; manufacturer: ACME Biomedical; expirationDate: Jan 1, 2022, 12:00:00 AM; lotNumber: M320; serialNumber: AC221; modelNumber: 1.0; <span title=\"Codes: {http://snomed.info/sct 19257004}\">Implant</span></a></table></div>"
  },
  "identifier" : [
    {
      "system" : "urn:ietf:rfc:3986",
      "value" : "urn:uuid:b2a737f2-2fdb-49c1-b097-dac173d07aff"
    }
  ],
  "status" : "completed",
  "code" : {
    "coding" : [
      {
        "system" : "http://www.ama-assn.org/go/cpt",
        "code" : "33249"
      }
    ],
    "text" : "Insertion or replacement of permanent implantable defibrillator system with transvenous lead(s), single or dual chamber"
  },
  "subject" : {
    "reference" : "Patient/example"
  },
  "performedPeriod" : {
    "start" : "2019-03-26T12:55:26-07:00",
    "end" : "2019-03-26T13:25:26-07:00"
  },
  "performer" : [
    {
      "actor" : {
        "reference" : "Practitioner/practitioner-1"
      }
    }
  ],
  "focalDevice" : [
    {
      "manipulated" : {
        "reference" : "Device/udi-2"
      }
    }
  ]
}

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

Next Page - PDex Provenance