Common CQL Artifacts for FHIR (US-Based)
2.0.0-ballot - Informative 2 Ballot

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: 2.0.0-ballot | Highlight text changes?
Standards status: Informative Active as of 2024-01-17 | 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.

- Tree view
- Sample Rendering
- Form Logic

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#2.0.0-ballot
request-info | Request Information | 0..1 | group | Value Set:
request-info|date-of-request | DATE OF REQUEST | 0..1 | date | Value Set:
diagnosis-info | Diagnosis Information | 0..1 | group | Value Set:
diagnosis-info|diagnosis | Diagnosis | 0..1 | string | Value Set:
item-requested | Item Requested | 0..1 | group | Value Set:
item-requested|item | Item requested | 0..1 | string | Value Set:
uti-history | UTI History | 0..1 | group | Value Set:
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 | Value Set:
uti-history|uti-dates | Dates of UTIs in the last year | 0..1 | string | Enable When: uti-history|uti-last-year = true Value Set:
uti-history|antibiotics-used | Antibiotics used for UTIs in the last year | 0..1 | string | Enable When: uti-history|uti-last-year = true Value Set:
symptoms-info | Symptoms Information | 0..1 | group | Value Set:
symptoms-info|symptoms | Check those that apply to your patient | 0..* | choice | Value Set: Options: 7 options
symptoms-info|fever-temperature | If fever, state temperature in degrees | 0..1 | decimal | Enable When: symptoms-info|symptoms = Fever (MNACQuestionnaire-symptoms-info-symptoms#Fever) Value Set:
catheterization-frequency | Catheterization Frequency | 0..1 | group | Value Set:
catheterization-frequency|frequency | How many times per day does the patient catheterize? | 0..1 | choice | Value Set: Options: 4 options
additional-comments | Additional Comments | 0..1 | group | Value Set:
additional-comments|comments | Additional Comment | 0..1 | string | Value Set:
physician-info | Physician Information | 0..1 | group | Value Set:
physician-info|name | Physician's Name | 0..1 | string | Value Set:
physician-info|mobile | Telephone | 0..1 | string | Value Set:
physician-info|fax | FAX | 0..1 | string | Value Set:
physician-info|signature | Physician's Signature | 0..1 | attachment | Value Set:
physician-info|phone-referring | Referring Physician Telephone | 0..1 | string | Value Set:
physician-info|date | Date | 0..1 | string | Value Set:
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")

Request Information

- linkId: request-info
- Answers:

DATE OF REQUEST

- linkId: request-info|date-of-request
- Answers:

Diagnosis Information

- linkId: diagnosis-info
- Answers:

Diagnosis

- linkId: diagnosis-info|diagnosis
- Answers:

Item Requested

- linkId: item-requested
- Answers:

Item requested

- linkId: item-requested|item
- Answers:

UTI History

- linkId: uti-history
- Answers:

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

- linkId: uti-history|uti-last-year
- Answers:

Dates of UTIs in the last year

- linkId: uti-history|uti-dates
- Enable When: todo
- Answers:

Antibiotics used for UTIs in the last year

- linkId: uti-history|antibiotics-used
- Enable When: todo
- Answers:

Symptoms Information

- linkId: symptoms-info
- Answers:

Check those that apply to your patient

- linkId: symptoms-info|symptoms
- Answers:
- Answers: 7 options

If fever, state temperature in degrees

- linkId: symptoms-info|fever-temperature
- Enable When: todo
- Answers:

Catheterization Frequency

- linkId: catheterization-frequency
- Answers:

How many times per day does the patient catheterize?

- linkId: catheterization-frequency|frequency
- Answers:
- Answers: 4 options

Additional Comments

- linkId: additional-comments
- Answers:

Additional Comment

- linkId: additional-comments|comments
- Answers:

Physician Information

- linkId: physician-info
- Answers:

Physician's Name

- linkId: physician-info|name
- Answers:

Telephone

- linkId: physician-info|mobile
- Answers:

FAX

- linkId: physician-info|fax
- Answers:

Physician's Signature

- linkId: physician-info|signature
- Answers:

Referring Physician Telephone

- linkId: physician-info|phone-referring
- Answers:

Date

- linkId: physician-info|date
- Answers:

LinkID | Description & Constraints
--- | ---
request-info | Value Set:
request-info|date-of-request | Value Set:
diagnosis-info | Value Set:
diagnosis-info|diagnosis | Value Set:
item-requested | Value Set:
item-requested|item | Value Set:
uti-history | Value Set:
uti-history|uti-last-year | Value Set:
uti-history|uti-dates | Enable When: Not done yet Value Set:
uti-history|antibiotics-used | Enable When: Not done yet Value Set:
symptoms-info | Value Set:
symptoms-info|symptoms | Value Set: Options: 7 options
symptoms-info|fever-temperature | Enable When: Not done yet Value Set:
catheterization-frequency | Value Set:
catheterization-frequency|frequency | Value Set: Options: 4 options
additional-comments | Value Set:
additional-comments|comments | Value Set:
physician-info | Value Set:
physician-info|name | Value Set:
physician-info|mobile | Value Set:
physician-info|fax | Value Set:
physician-info|signature | Value Set:
physician-info|phone-referring | Value Set:
physician-info|date | Value Set:
Documentation for this format

#### Contained resources

- EffectiveDataRequirements

### Test this Questionnaire

Try this questionnaire out:

- NLM Forms Library

### Responses for this Questionnaire

There are currently no QuestionnaireResponse instances for this Questionnaire defined in this IG.