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CDAR1AIS0010R010 Additional Information Specification 0010: Drug Prior Authorization Attachment Release 1.0 Based on HL7 CDA Standard Release 1.0, with supporting LOINC® Tables Draft - December 2006 Copyright © 1998-2005 Health Level Seven. All Rights Reserved. Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 This page intentionally blank Page ii November 2005 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 Table of Contents 1 INTRODUCTION ............................................................................................................................................... 1 1.1 1.2 1.3 1.4 1.5 2 LOINC CODES AND STRUCTURE ..................................................................................................................... 2 REVISION HISTORY .......................................................................................................................................... 4 PRIVACY CONCERNS IN EXAMPLES .................................................................................................................. 4 HL7 ATTACHMENT-CDA DOCUMENT VARIANTS............................................................................................ 4 REQUEST FOR INFORMATION VERSUS REQUEST FOR SERVICE ......................................................................... 4 LOINC CODES ................................................................................................................................................... 5 2.1 SUPPORTING DOCUMENTATION ....................................................................................................................... 5 2.2 SCOPE MODIFICATION CODES .......................................................................................................................... 5 2.3 SPECIAL CONSIDERATIONS .............................................................................................................................. 5 2.4 ATTACHMENT DATA COMPONENTS ................................................................................................................. 6 2.4.1 Drug Request - Unspecified Therapeutic Category Attachment ............................................................ 6 2.4.2 NSAIDS - COX2 Inhibitors Attachment ............................................................................................... 6 2.4.3 Growth Hormone Attachment ............................................................................................................... 6 2.4.4 Proton Pump Inhibitors Attachment ...................................................................................................... 7 2.4.5 Erectile Dysfunction (ED) Agents Attachment ..................................................................................... 7 2.4.6 Narcotic (OPIOID) Agonists Attachment .............................................................................................. 8 2.4.7 Imidazole - Related Antifungals Attachment ........................................................................................ 8 3 DRUG PRIOR AUTHORIZATION ATTACHMENT VALUE TABLES .................................................... 8 3.1 3.2 3.3 3.4 3.5 3.6 3.7 4 DRUG REQUEST - UNSPECIFIED THERAPEUTIC CATEGORY (UTC) SERVICE VALUE TABLE............................. 9 NSAIDS - COX2 INHIBITORS VALUE TABLE ................................................................................................ 12 GROWTH HORMONE (GH) VALUE TABLE ...................................................................................................... 15 PROTON PUMP INHIBITORS (PPI) VALUE TABLE ............................................................................................ 23 ERECTILE DYSFUNCTION (ED) AGENTS VALUE TABLE ................................................................................. 27 NARCOTIC(OPIOID) AGONISTS VALUE TABLE ............................................................................................... 32 IMIDAZOLE - RELATED ANTIFUNGALS VALUE TABLE ................................................................................... 37 CODING EXAMPLES ..................................................................................................................................... 43 4.1 SCENARIO ...................................................................................................................................................... 43 4.1.1 Drug Prior Authorization Attachment, Human-Decision Variant (XML body) .................................. 44 4.1.2 Drug Prior Authorization Attachment, Human-Decision Variant (non-XML body) ........................... 49 4.1.3 Coded Drug Prior Authorization Attachment, Computer-Decision Variant ........................................ 52 5 RESPONSE CODE SETS ................................................................................................................................. 58 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 5.10 5.11 5.12 5.13 5.14 5.15 5.16 HL70136: YES-NO INDICATOR ..................................................................................................................... 58 HL79038: DRUG PRESCRIBED, THERAPY TYPE ............................................................................................. 58 HL79039: UTC, DIAGNOSIS CONFIRMED BY ............................................................................................... 58 HL79040: REASON PRIOR THERAPY DISCONTINUED .................................................................................... 59 HL79041: NSAIDS/PPI RELATED CONCURRENT THERAPY, TYPE ............................................................... 59 HL79042: NSAID USE, DURATION .............................................................................................................. 59 HL79043: YES-NO-UNKNOWN INDICATOR ................................................................................................... 59 HL79044: RADIOLOGY DIAGNOSIS CONFIRMATION, STUDY TYPE ................................................................ 60 HL79045: LABORATORY DIAGNOSIS CONFIRMATION, STUDY/TEST ............................................................ 60 HL79046: GH, PATIENT HISTORY – DOCUMENTED ONSET...................................................................... 60 HL79047: GH, PATIENT HISTORY INFORMATION – HYPOTHALMIC PITUITARY DISEASE INDUCED BY.... 60 HL79048: TREATMENT STATUS ............................................................................................................... 61 HL79049: GHD CHILDHOOD INFORMATION, PUBERTY STATUS .............................................................. 61 HL79050: GH DYSFUNCTION ADULT INFORMATION, SECONDARY CAUSES ............................................ 61 HL79051: NUTRITIONAL INFORMATION, ASSESSMENT INDICATOR ......................................................... 61 HL79052: PARENTAL HEIGHT, AVAILABILITY INDICATOR ...................................................................... 61 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page iii November 2005 Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 5.17 HL79053: DIAGNOSIS CONFIRMATION AND LEVEL OF TREATMENT NEEDED, PROCEDURE EMPLOYED ...62 5.18 HL79054: DIAGNOSIS CONFIRMATION AND LEVEL OF TREATMENT NEEDED, GERD BY ENDOSCOPY TYPE 62 5.19 HL79055: H-PYLORI INFORMATION, STATUS...........................................................................................62 5.20 HL79056: H-PYLORI INFORMATION, CONFIRMED BY ..............................................................................62 5.21 HL79057: ED, RELATED DIAGNOSIS CONFIRMATION, CONFIRMED BY ...................................................63 5.22 HL79058: ED, PATIENT HISTORY – PULMONARY HYPERTENSION FUNCTIONAL LEVEL ..........................63 5.23 HL79059: ED, PATIENT HISTORY – EVALUATION TYPE ..........................................................................63 5.24 HL79060: ED, PATIENT HISTORY – ED RELATED TO ..............................................................................63 5.25 HL79061: ED, TREATMENT OF RELATED CAUSES – PSYCHOGENIC CAUSES OF ED TREATMENT ............64 5.26 HL79062: ED, TREATMENT OF RELATED CAUSES – DRUG INDUCED OPTION ..........................................64 5.27 HL79063: ED CONCURRENT THERAPY, TYPE ..........................................................................................64 5.28 HL79064: NARCOTIC (OPIOID) AGONISTS, PATIENT HISTORY – PAIN SYNDROME SOURCE .....................64 5.29 HL79065: NARCOTIC (OPIOID) AGONISTS, PATIENT HISTORY – PAIN SYNDROME HISTORY ...................65 5.30 HL79066: NARCOTIC (OPIOID) AGONISTS, PATIENT HISTORY – PAIN SYNDROME PERSISTENCE.............65 5.31 HL79067: NARCOTIC (OPIOID) AGONISTS, COMPLICATING CONDITIONS ................................................65 5.32 HL79068: OPIOID RELATED CONCURRENT PAIN THERAPY, OPIOID LEVEL .............................................65 5.33 HL79069: DRUG PRESCRIBED, TOPICAL THERAPY - REASON ..................................................................66 5.34 HL79070: IMIDAZOLE – RELATED ANTIFUNGALS, DIAGNOSIS CONFIRMED BY .......................................66 5.35 HL79071: FUNGAL INFECTION INFORMATION, LOCATION .......................................................................66 5.36 HL79072: IMMUNE COMPROMISE INFORMATION, CAUSE ........................................................................66 5.37 HL79073: IMMUNE COMPROMISE INFORMATION, VERIFIED BY ..............................................................66 5.38 HL79074: CO-MORBID CONDITION INFORMATION, LIVER DYSFUNCTION – CONFIRMED BY ..................67 5.39 HL79075: LEVEL OF FUNCTIONAL IMPAIRMENT ......................................................................................67 5.40 HL79076: IMIDAZOLE – RELATED ANTIFUNGALS, PRIOR THERAPY TYPE ...............................................67 5.41 I9C : ICD-9-CM ........................................................................................................................................67 5.42 IC10: ICD-10-CM ....................................................................................................................................67 5.43 ISO+: EXTENDED ISO UNITS CODES ..........................................................................................................68 5.44 NDC: NATIONAL DRUG CODE ..................................................................................................................68 5.45 RXNC: RXNORM SCD (SEMANTIC CLINICAL DRUG) ...............................................................................68 5.46 RXNB: RXNORM SBD (SEMANTIC BRANDED DRUG) ..............................................................................68 5.47 DEA: DRUG ENFORCEMENT ADMINISTRATION .........................................................................................68 5.48 HCI: HCIDEA ............................................................................................................................................69 5.49 NPI: NATIONAL PROVIDER IDENTIFIER .....................................................................................................69 5.50 PTX: HEALTH CARE PROVIDER TAXONOMY .............................................................................................70 5.51 MISCELLANEOUS OID REFERENCES ..........................................................................................................70 5.51.1 Unique Instance Identifier ....................................................................................................................70 5.51.2 person_name.type_cd ...........................................................................................................................70 5.51.3 Proprietary Provider ID ........................................................................................................................70 5.51.4 Example OID .......................................................................................................................................70 Page iv November 2005 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 Index of Tables and Figures Table 1.1 Relationship of LOINC Codes, X12N Transactions, and HL7 CDA Documents. ........................................ 3 Table 2.1 LOINC codes for a complete Drug Prior Authorization attachment data set ................................................ 5 Table 2.4.1 Data Components for Drug Request - Unspecified Therapeutic Category (UTC) Attachment .................. 6 Table 2.4.2 Data Components for NSAIDS - COX2 Inhibitors Attachment ................................................................. 6 Table 2.4.3 Data Components for Growth Hormone (GH) Attachment ........................................................................ 6 Table 2.4.4 Data Components for Proton Pump Inhibitors (PPI) Attachment ............................................................... 7 Table 2.4.5 Data Components for Erectile Dysfunction Agents Attachment ................................................................ 7 Table 2.4.6 Data Components for Narcotic Agonists Attachment ................................................................................ 8 Table 2.4.7 Data Components for Imidazole - Related Antifungals Attachment .......................................................... 8 Table 3.1 Drug Request - Unspecified Therapeutic Category Value Table .................................................................. 9 Table 3.2 NSAIDS - COX2 Inhibitors Value Table .................................................................................................... 12 Table 3.3 Growth Hormone Value Table .................................................................................................................... 15 Table 3.4 Proton Pump Inhibitors Value Table ........................................................................................................... 23 Table 3.5 Erectile Dysfunction Agents Value Table ................................................................................................... 27 Table 3.6 Narcotic(Opioid) Agonists Value Table ...................................................................................................... 32 Table 3.7 Imidazole - Related Antifungals Value Table ............................................................................................. 37 Figure 4.1 Drug Prior Authorization Additional Data ................................................................................................. 43 Example 4.1.1 Drug Prior Authorization Attachment, Human-Decision Variant (XML body) .................................. 44 Figure 1. Rendered Human-Decision Variant (XML body) ........................................................................................ 46 Example 4.1.2 Drug Prior Authorization Attachment, Human-Decision Variant (non-XML body)........................... 49 Figure 2. Rendered Human-Decision Variant (non-XML body) ................................................................................. 50 Example 4.1.2 Drug Prior Authorization Attachment, Computer-Decision Variant ................................................... 52 Figure 3. Rendered Human-Decision Variant (non-XML body) ................................................................................. 56 Table 5.1 Yes-No Indicator ......................................................................................................................................... 58 Table 5.2 Drug Prescribed, Therapy Type................................................................................................................... 58 Table 5.3 UTC, Diagnosis Confirmed By .................................................................................................................. 58 Table 5.4 Reason Prior Therapy Discontinued ............................................................................................................ 59 Table 5.5 NSAIDS – COX 2 Inhibitors, Concurrent Therapy - Type ......................................................................... 59 Table 5.6 NSAID Use, Duration ................................................................................................................................. 59 Table 5.7 HL7 NSAID Use, Duration ........................................................................................................................ 59 Table 5.8 Radiology Diagnosis Confirmation, Study Type ......................................................................................... 60 Table 5.9 Laboratory Diagnosis Confirmation, Study/Test ......................................................................................... 60 Table 5.10 GH, Patient History – Documented Onset ................................................................................................. 60 Table 5.11 GH, Patient History Information – Hypothalmic Pituitary Disease Induced By ....................................... 60 Table 5.12 Treatment Status ........................................................................................................................................ 61 Table 5.13 GHD Childhood Information, Puberty Status............................................................................................ 61 Table 5.14 GH Dysfunction Adult Information, Secondary Causes ............................................................................ 61 Table 5.15 Nutritional Information, Assessment Indicator ......................................................................................... 61 Table 5.16 Parental Height, Availability Indicator ...................................................................................................... 62 Table 5.17 Diagnosis Confirmation and Level Treatment Needed, Procedure Employed .......................................... 62 Table 5.18 Diagnosis Confirmation and Level of Treatment Needed, GERD By Endoscopy Type ........................... 62 Table 5.19 H-Pylori Information, Status ..................................................................................................................... 62 Table 5.20 H-Pylori Information, Confirmed By ........................................................................................................ 62 Table 5.21 ED, Related Diagnosis Confirmation, Confirmed By ............................................................................... 63 Table 5.22 ED, Patient History – Pulmonary Hypertension Functional Level ............................................................ 63 Table 5.23 ED, Patient History – Evaluation Type ..................................................................................................... 63 Table 5.24 ED, Patient History – ED Related To ........................................................................................................ 63 Table 5.25 ED, Treatment of Related Causes – Psychogenic Causes of ED Treatment ............................................. 64 Table 5.26 ED, Treatment of Related Causes – Drug Induced Option ........................................................................ 64 Table 5.27 ED Concurrent Therapy, Type .................................................................................................................. 64 Table 5.28 Narcotic (Opioid) Agonists, Patient History – Pain Syndrome Source ..................................................... 64 Table 5.29 Narcotic (Opioid) Agonists, Patient History – Pain Syndrome History .................................................... 65 Table 5.30 Narcotic (Opioid) Agonists, Patient History – Pain Syndrome Persistance .............................................. 65 Table 5.31 Narcotic (Opioid) Agonists, Complicating Conditions ............................................................................. 65 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page v November 2005 Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 Table 5.32 Opioid Concurrent Pain Therapy, Opioid Level ........................................................................................65 Table 5.33 Drug Prescribed, Topical Therapy - Reason ..............................................................................................66 Table 5.34 Imidazole – Related Antifungals, Diagnosis Confirmed By ......................................................................66 Table 5.35 Fungal Infection Information, Location .....................................................................................................66 Table 5.36 Immune Compromise Information, Cause .................................................................................................66 Table 5.37 Immune Compromise Information, Verified By........................................................................................66 Table 5.38 Co-Morbid Condition Information, Liver Dysfunction – Confirmed By ..................................................67 Table 5.39 Level of Functional Impairment ................................................................................................................67 Table 5.40 Imidazole – Related Antifungals, Prior Therapy Type .............................................................................67 Page vi November 2005 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 1 Introduction This publication provides the LOINC®1 code values specific to a Drug Prior Authorization attachment for the following applications. Those codes that define the attachment or attachment components used in transactions such as those defined by the ASC X12N 278 (005010X215) Health Care Services Review Response and the ASC X12N 275 (005010X215) Additional Information to Support a Health Care Services Review Implementation Guides which are products of the insurance subcommittee, X12N, of Accredited Standards Committee X12.2,3 All of the codes may be used in HL7 Clinical Document Architecture (CDA) documents designed for inclusion in the BIN segment of the 275 transaction as described in the HL7 Additional Information Specification Implementation Guide4 The format of this document and the methods used to arrive at its contents are prescribed in the HL7 Additional Information Specification Implementation Guide. Additional Information Specification 0010: Drug Prior Authorization Attachment is designed to facilitate the transmission of information necessary to evaluate and support the medical necessity for a drug being ordered for a patient. As the deployment of e-Prescribing and Electronic Health Records expands and the technology matures, it is anticipated that this AIS will become an integral part of a fully automated prescription, authorization and delivery process. Most health plans make use of a prior authorization process, either for specified classes of drugs or for atypical use of a drug. The attachment component specifications included represent the most commonly requested documentation requirements. These were developed in collaboration with the National Council for Prescription Drug Programs (NCPDP), Work Group 11 Prescriber/Pharmacist Interface, Prior Authorization Transfer Task Group. Additional components will be developed as the industry needs are assessed and defined. Section 2 of this document defines the LOINC codes used to request Drug Prior Authorization attachments and the LOINC codes of each component in an attachment. Section 3 further describes each component of the Drug Prior Authorization attachment, the cardinality of the components and their answer parts, and the description, data types, codes, and units of each answer part. Section 4 presents coding examples, with a narrative scenario, an XML example, and a display image of each example attachment using a popular browser. Section 5 further describes the code sets used in the response to each answer part of the attachment. Note: All LOINC codes and descriptions are copyrighted by the Regenstrief Institute, with all rights reserved. See http://www.LOINC.org. 1 LOINC® is a registered trademark of Regenstrief Institute and the LOINC Committee. The LOINC database and LOINC Users’ Guide are copyright 1998-2005 Regenstrief Institute and the LOINC Committee and the LOINC database codes and names are available at no cost from http://www.LOINC.org. Regenstrief Institute, 1050 Wishard Blvd., Indianapolis, IN 46202 Email: [email protected] 2 Information on this and other X12N/HIPAA-related implementation guides is available from the Washington Publishing Company, PMB 161, 5284 Randolph Rd., Rockville, MD 20852-2116. Phone: 800-972-4334. or http://www.wpc-edi.com/ 3 Within this Health Level Seven document, references to the transaction defined by these X12N implementation guides will be abbreviated by calling them 275 and 277. 4 Health Level Seven, Inc. 3300 Washtenaw Ave., Suite 227, Ann Arbor, MI 48104-4250. (http://www.hl7.org) Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page 1 November 2005 Additional Information Specification 0010: PharmPA Attachment 1.1 CDAR1AIS0010R010 LOINC Codes and Structure LOINC codes are used for several purposes: Page 2 November 2005 In the X12N 278 transaction set, LOINC codes identify the attachment or attachment components being requested to support a claim or encounter. In the HL7 CDA document, LOINC codes are used to identify the attachment, the attachment components, and their answer parts. This is returned in the X12N 275 transaction set. LOINC modifier codes may be used in the 278 transaction to further define the specificity of a request. Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 Table 1.1 Relationship of LOINC Codes, X12N Transactions, and HL7 CDA Documents. X12N 278 Purpose of Attachment LOINC Modifier Codes LOINC Attachment Identifier LOINC Attachment Component LOINC Attachment Component Answer Part Health Care Services Review Response Used in the STC segment to limit the scope or time frame of a request for information. e.g., Send information for up to 90 days before the related request. Used in the STC segment to request an attachment in its entirety, e.g., Send the Proton Pump Inhibitors Attachment. Used in the STC segment to request a specific attachment component or part of a clinical report, .e.g., Send the H-Pylori Treatment Information Not used in the 278 X12N 275 Additional Information to Support a Health Care Services Review Reiterated in the STC segment Reiterated in the STC segment Reiterated in the STC segment Not used in the 275 except within the CDA instance document in the BIN segment. Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard HL7 CDA Provide controlled content for X12N 275 BIN segment Not used in the CDA document Used in the <document_type_cd> element of the header Used in the computerdecision CDA variant in the <caption_cd> element of a <section> to identify the attachment component being provided, e.g., This is information regarding H-Pylori Treatment. Used in the computerdecision CDA variant in the <caption_cd> element of a <paragraph>, an <item> element within a <list> or a <td> element within a <table> to identify the answer part of an attachment component being provided, e.g., This is the patient’s current height. Page 3 November 2005 Additional Information Specification 0010: PharmPA Attachment 1.2 Revision History Date Initial Release for Review First Ballot 1.3 CDAR1AIS0010R010 Purpose December 2005 March 2006 Privacy Concerns in Examples The names of natural persons that appear in the examples of this book are intentionally fictional. Any resemblance to actual natural persons, living or deceased is purely coincidental. 1.4 HL7 Attachment-CDA Document Variants As described in the HL7 Additional Information Specification Implementation Guide, there are two variants of a CDA document when used as an attachment. The human-decision variant is used solely for information that will be rendered for a person to look at, in order to make a decision. HL7 provides a non-normative style sheet for this purpose. There are two further alternatives within the human-decision variant. non_xml body: The information can be sent with a CDA header structured in XML, along with a "non_xml body" that references scanned images of documents that contain the submitted information xml body: the information can be sent as free text in XML elements that organize the material into sections, paragraphs, tables and lists as described in the HL7 Additional Information Specification Implementation Guide. The computer-decision variant has the same content as the human-decision variant, but additional coded and structured information is included so that a computer could provide decision support based on the document. Attachments in the computer-decision variant can be rendered for human decisions using the same style sheet that HL7 provides for rendering documents formatted according to the human-decision variant. 1.5 Request for Information versus Request for Service This attachment specification for Drug Prior Authorization defines a “send-me-what-you-have” attachment. It asks for a set of Drug Prior Authorization attachment components needed for the Drug Prior Authorization process. It is not asking for any additional data capture efforts. For example, if the request for data is to send the length of time the patient is expected to need the medication at the requested dose level, it is not asking the provider to obtain additional information if they don’t already have this information. In any attachment component answer part it may sometimes be impossible to send a required answer and necessary to send, instead, a reason why the information is not available. In the human decision variant the sender shall supplement the natural language explanation of why the information is not available with local markup. In the computer-decision variant the sender shall Page 4 November 2005 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 include local markup to describe the reason that the information is not available as described in the Data Types section of the HL7 Additional Information Specification Implementation 2 LOINC Codes 2.1 Supporting Documentation Table 2.1 defines the LOINC codes used to request a complete attachment data set for Drug Prior Authorization. The use of any of these codes in the 278 HI or PWK segments represents an explicit request for the complete set of data components relevant to the drug prior authorization. The provider shall return all data components for which data is available. The provider may choose to return images of pages that constitute the requested information by using the <non_xml> element of the CDA as described in the HL7 Additional Information Specification Implementation Guide. The set of data components for the Drug Prior Authorization attachment, identified by individual LOINC codes, is defined in Section 2.4. NOTE: The LOINC values represented in this draft ballot version are included as representative examples and are not the actual LOINC values that will be used for this attachment. Once the AIS has been approved, the actual LOINC values will be requested from Regenstrief and included in the final published version. The final check digit (after the hyphen) indicates for example purposes only, the specific drug attachment category. Where a component or answer part is re-used in the document, the sample LOINC value is repeated to indicate this re-use. The final check digit will be an “x” to indicate that it is used in more than one drug attachment category. Table 2.1 LOINC codes for a complete Drug Prior Authorization attachment data set LOINC code 99999-1 99999-2 99999-3 99999-4 99999-5 99999-6 99999-7 Attachment Name Drug Request – Unspecified Therapeutic Category Attachment NSAIDS – COX2 Inhibitors Attachment Growth Hormone Attachment Proton Pump Inhibitors Attachment Erectile Dysfunction Agents Attachment Narcotic (Opioid) Agonists Attachment Imidazole – Related Antifungals Attachment 2.2 Scope Modification Codes The HL7 publication LOINC Modifier Codes (for use with ASC X12N Implementation Guides when Requesting Additional Information) provides code values for further defining the specificity of a request for additional information. Both time window and item selection modifier codes are defined. This publication is available from HL7, and is in the download package with the AIS documents. 2.3 Special Considerations Intentionally left blank. Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page 5 November 2005 Additional Information Specification 0010: PharmPA Attachment 2.4 CDAR1AIS0010R010 Attachment Data Components Individual LOINC codes are defined for each data component of the attachment specific to the therapeutic drug category listed in Table 2.1. These LOINC codes are listed in sections 2.4.1 to 2.4.7 respectively. For example, the data components comprising the cardiac rehabilitation attachment (LOINC 18824-3) appear in Table 2.4.2. Each table is headed by the LOINC code defining the complete attachment. The LOINC codes in Table 2.1 represent requests for complete Drug Prior Authorization attachments. However, the requester also has the option of focusing on a specific component of the attachment through the use of the LOINC codes defined in the following tables. In this case the provider will respond with information, where available, specific to the requested data components. These LOINC codes may be used in ASC X12N 278 as defined in the associated Implementation Guide and will be mirrored in the corresponding ASC X12N 275 response. In addition, these LOINC codes are used in the <caption_cd> element of the computer-decision variant of HL7 Additional Information Specification Implementation Guide. The questions that these LOINC codes represent are the result of a significant industry outreach project and represent the complete set of Drug Prior Authorization attachment components at this time. Additional drug therapeutic categories may be added to this document at a later date. 2.4.1 Drug Request - Unspecified Therapeutic Category Attachment Table 2.4.1 Data Components for Drug Request - Unspecified Therapeutic Category (UTC) Attachment LOINC Code 99999-1 90010-x 90020-x 90030-x 90040-1 90050-1 90060-1 90070-x 90080-x 90090-x Description DRUG REQUEST - UNSPECIFIED THERAPEUTIC CATEGORY ATTACHMENT PRESCRIBER INFORMATION (COMPOSITE) PRESCRIBER CONTACT INFORMATION (COMPOSITE) DRUG PRESCRIBED (COMPOSITE) UTC, MEDICAL NECESSITY INFORMATION UTC, RELATED DIAGNOSIS INFORMATION (COMPOSITE) UTC, ADDITIONAL CONFIRMATION INFORMATION MEDICARE ESRD CERTIFICATION DATE DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS (COMPOSITE) CONCURRENT THERAPY (COMPOSITE) 2.4.2 NSAIDS - COX2 Inhibitors Attachment Table 2.4.2 Data Components for NSAIDS - COX2 Inhibitors Attachment LOINC Code 99999-2 90010-x 90020-x 90030-x 90100-2 90080-x 90090-x 90110-x 90120-2 Description NSAIDS - COX2 INHIBITORS ATTACHMENT PRESCRIBER INFORMATION (COMPOSITE) PRESCRIBER CONTACT INFORMATION (COMPOSITE) DRUG PRESCRIBED (COMPOSITE) NSAIDS-COX2 INHIBITORS, RELATED DIAGNOSIS DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS (COMPOSITE) CONCURRENT THERAPY (COMPOSITE) NSAIDS/PPI RELATED CONCURRENT THERAPY (COMPOSITE) NSAID USE (COMPOSITE) 2.4.3 Growth Hormone Attachment Table 2.4.3 Data Components for Growth Hormone (GH) Attachment Page 6 November 2005 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment LOINC Code 99999-3 90010-x 90020-x 90030-x 90130-3 90140-3 90150-3 90160-3 90170-3 90180-3 90190-3 90200-3 90210-3 90220-3 90230-3 90240-3 90250-3 90080-x 90090-x CDAR1AIS0010R010 Description GROWTH HORMONE ATTACHMENT PRESCRIBER INFORMATION (COMPOSITE) PRESCRIBER CONTACT INFORMATION (COMPOSITE) DRUG PRESCRIBED (COMPOSITE) GH, RELATED DIAGNOSIS RADIOLOGICAL DIAGNOSIS CONFIRMATION INFORMATION (COMPOSITE) LABORATORY DIAGNOSIS CONFIRMATION INFORMATION (COMPOSITE) GH, PATIENT HISTORY INFORMATION (COMPOSITE) GHD CHILDHOOD INFORMATION (COMPOSITE) GH DYSFUNCTIONADULT INFORMATION (COMPOSITE) WASTING SYNDROME INFORMATION (COMPOSITE) NUTRITIONAL INFORMATION (COMPOSITE) LABORATORY GH STIMULATION (COMPOSITE) PHYSICIAL FINDINGS, PATIENT HEIGHT (COMPOSITE) PHYSICIAL FINDINGS, PATIENT WEIGHT (COMPOSITE) PATIENT BODY MASS INDEX (COMPOSITE) PARENTAL HEIGHT (COMPOSITE) DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS (COMPOSITE) CONCURRENT THERAPY (COMPOSITE) 2.4.4 Proton Pump Inhibitors Attachment Table 2.4.4 Data Components for Proton Pump Inhibitors (PPI) Attachment LOINC Code 99999-4 90010-x 90020-x 90030-x 90260-4 90270-4 90280-4 90080-x 90090-x 90110-x 90290-4 90300-4 Description PROTON PUMP INHIBITORS ATTACHMENT PRESCRIBER INFORMATION (COMPOSITE) PRESCRIBER CONTACT INFORMATION (COMPOSITE) DRUG PRESCRIBED (COMPOSITE) PPI, RELATED DIAGNOSIS DIAGNOSIS CONFIRMATION AND LEVEL OF TREATMENT NEEDED (COMPOSITE) PPI, PATIENT HISTORY – STRICTURE PRESENT DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS (COMPOSITE) CONCURRENT THERAPY (COMPOSITE) NSAIDS/PPI RELATED CONCURRENT THERAPY (COMPOSITE) H-PYLORI INFORMATION (COMPOSITE) H-PYLORI TREATMENT (COMPOSITE) 2.4.5 Erectile Dysfunction (ED) Agents Attachment Table 2.4.5 Data Components for Erectile Dysfunction Agents Attachment LOINC Code 99999-5 90010-x 90020-x 90030-x 90310-5 90320-5 90330-5 90340-5 90080-x 90090-x 90340-5 Description ERECTILE DYSFUNCTION AGENTS ATTACHMENT PRESCRIBER INFORMATION (COMPOSITE) PRESCRIBER CONTACT INFORMATION (COMPOSITE) DRUG PRESCRIBED (COMPOSITE) ED, RELATED DIAGNOSIS ED, RELATED DIAGNOSIS CONFIRMATION INFORMATION (COMPOSITE) ED, PATIENT HISTORY INFORMATION (COMPOSITE) ED, TREATMENT OF RELATED CAUSES (COMPOSITE) DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS (COMPOSITE) CONCURRENT THERAPY (COMPOSITE) ED RELATED CONCURRENT THERAPY (COMPOSITE) Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page 7 November 2005 Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 2.4.6 Narcotic (OPIOID) Agonists Attachment Table 2.4.6 Data Components for Narcotic Agonists Attachment LOINC Code 99999-6 90010-x 90020-x 90030-x 90360-6 90370-6 90380-6 90390-6 90080-x 90090-x 90400-6 90410-6 Description NARCOTIC (OPIOID) AGONISTS ATTACHMENT PRESCRIBER INFORMATION (COMPOSITE) PRESCRIBER CONTACT INFORMATION (COMPOSITE) DRUG PRESCRIBED (COMPOSITE) NARCOTIC (OPIOID) AGONISTS, RELATED DIAGNOSIS NARCOTIC (OPIOID) AGONISTS, PATIENT HISTORY (COMPOSITE) NARCOTIC (OPIOID) AGONISTS, COMPLICATING CONDITIONS INFORMATION (COMPOSITE) NARCOTIC (OPIOID) AGONISTS, LABORATORY INFORMATION (COMPOSITE) DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS (COMPOSITE) CONCURRENT THERAPY (COMPOSITE) OPIOD RELATED CONCURRENT PAIN THERAPY (COMPOSITE) NARCOTIC (OPIOID) AGONISTS, USE FOR TREATMENT OF OPIOID ADDICTION 2.4.7 Imidazole - Related Antifungals Attachment Table 2.4.7 Data Components for Imidazole - Related Antifungals Attachment LOINC Code 99999-7 90010-x 90020-x 90030-x 90420-7 90430-7 90440-7 90450-7 90460-7 90070-x 90470-7 90480-7 90080-x 90490-7 90090-x Description IMIDAZOLE - RELATED ANTIFUNGALS ATTACHMENT PRESCRIBER INFORMATION (COMPOSITE) PRESCRIBER CONTACT INFORMATION (COMPOSITE) DRUG PRESCRIBED (COMPOSITE) DRUG PRESCRIBED, TOPICAL THERAPY (COMPOSITE) IMIDAZOLE - RELATED ANTIFUNGALS, RELATED DIAGNOSIS INFORMATION (COMPOSITE) FUNGAL INFECTION INFORMATION (COMPOSITE) IMMUNE COMPROMISE INFORMATION (COMPOSITE) CO-MORBID CONDITION INFORMATION (COMPOSITE) MEDICARE ESRD CERTIFICATION DATE LEVEL OF FUNCTIONAL IMPAIRMENT INPATIENT TREATMENT INFORMATION (COMPOSITE) DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS (COMPOSITE) IMIDAZOLE - RELATED ANTIFUNGALS, PRIOR THERAPY TYPE CONCURRENT THERAPY (COMPOSITE) 3 Drug Prior Authorization Attachment Value Tables Each of the tables in this section further describes the LOINC components listed in the above corresponding table, along with the expected answer part(s) for each question, including the data type, cardinality, and codes/units for each answer. The minimum attachment data set equates to the required components; those identified in the value table, below, with cardinality (Card) of {1,1} (component is required and has one and only one occurrence) or {1,n} (component is required and has one or more occurrences). Those data components with a cardinality of {0,1} (if available has one and only one occurrence) or {0,n} (if available may have one or more occurrences) shall be sent if available. Page 8 November 2005 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment 3.1 CDAR1AIS0010R010 Drug Request - Unspecified Therapeutic Category (UTC) Service Value Table Table 3.1 Drug Request - Unspecified Therapeutic Category Value Table LOINC code Component Answer 90010-x Value Data Type PRESCRIBER INFORMATION Information about the practitioner prescribing the drug. Card 1,1 90011-x PRESCRIBER INFORMATION, NAME This is the name of the practitioner prescribing the drug. PN 1,1 90012-x PRESCRIBER INFORMATION, IDENTIER This may be repeated to convey multiple identifiers such as the National Provider Identifier (NPI), Drug Enforcement Act number (DEA), Special DEA number, HCIdea Number or proprietary provider identifier. CX 1,n Note: If the provider is a covered entity under HIPAA and the NPI is mandated for use, the NPI must be sent as one of the identifiers and the legacy provider identifier must not be used. 90013-x PRESCRIBER INFORMATION, SPECIALTY TAXONOMY CODE This is the Taxonomy code that represents the medical specialty of the prescriber. 90020-x 90030-x NPI DEA HCIdea Proprietary Provider ID See note at left. CE PRESCRIBER CONTACT INFORMATION Contact information for the individual prescribing the drug. 1,1 PTX 0,1 90021-x PRESCRIBER CONTACT INFORMATION, PHONE NUMBER The phone number of the individual prescribing the drug. TX 1,1 90022-x PRESCRIBER CONTACT INFORMATION, FAX NUMBER The fax number of the individual prescribing the drug. TX 0,1 DRUG PRESCRIBED This is information about the drug requested in the prior authorization. 1,1 90031-x DRUG PRESCRIBED, NAME This is the descriptive name of the drug prescribed. TX 1,1 90032-x DRUG PRESCRIBED, DRUG CODE This is the code identifier for the drug prescribed as defined by Representative NDC, RxNorm SCD or RxNorm SBD. CE 1,1 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Response Code / Numeric Units NDC RxNorm SCD RxNorm SBD Page 9 November 2005 Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value 90033-x DRUG PRESCRIBED, THERAPY TYPE This is used to convey the historical use of the prescribed drug as part of the patient’s therapy. INTRQ CNTRQ RPLRQ ADDRQ CDAR1AIS0010R010 Data Type Card Response Code / Numeric Units CE 1,1 HL79038 0,1 HL70136 Initial Therapy Continued Therapy Replacement Therapy Add on Therapy 90034-x DRUG PRESCRIBED, SELF ADMINISTERED INDICATOR This indicator defines if the drug can be self administered. N No Y Yes 90040-1 UTC, MEDICAL NECESSITY INFORMATION Additional information as required to support the medical necessity of the requested medication therapy. This is submitted based on the plan or UMO's defined requirements for the drug. 90040-1 90050-1 0,1 TX UTC, RELATED DIAGNOSIS INFORMATION Diagnosis information related to the prescribed drug. 90051-1 UTC, RELATED DIAGNOSIS This is the related diagnosis of the patient for which the drug is a prescribed therapy. 1,1 1,1 CE 1,1 IC9 IC10 CE 0,n HL79039 90053-1 UTC, DIAGNOSIS CONFIRMED BY – DATE OF CLINICAL DT EVALUATION This is the date the confirmatory clinical evaluation was performed. 01 Note: Prior to U.S. adoption of ICD-10-CM, use ICD-9-CM in the U.S. domain. After adoption as the standard for defining diagnoses in the US, use only ICD-10-CM for requests in the US. 90052-1 UTC, DIAGNOSIS CONFIRMED BY This conveys the means by which the diagnosis was established- diagnostic procedures and/or clinical observation. LABT RADT OTDX CLNE 90060-1 Laboratory Examination Radiological Examination Other Diagnostic Examination Clinical Evaluation UTC, ADDITIONAL CONFIRMATION INFORMATION This is used to convey information about the diagnostic study used to confirm the diagnosis. It is required when the answer to Unspecified Therapeutic Category, Diagnosis Confirmed By is equal to “LABT” Laboratory Examination, “RADT” Radiological Examination, or “OTDX” Other Diagnostic Examination. 90061-1 UTC, ADDITIONAL CONFIRMATION INFORMATION NAME OF TEST This is used to convey the name of the diagnostic study used to confirm the diagnosis. Page 10 November 2005 0,n TX 0,1 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value Data Type Card 90062-1 UTC, ADDITIONAL CONFIRMATION INFORMATION TEST RESULT This is the result of the diagnostic procedure by which the diagnosis was confirmed. It is required when the answer to Unspecified Therapeutic Category, Diagnosis Confirmed By is equal to “LABT” Laboratory Examination. NM 0,1 90063-1 UTC, ADDITIONAL CONFIRMATION INFORMATION DATE OF TEST OR OBSERVATION This is the date the confirmatory diagnostic study. DT 1,1 90070-x MEDICARE ESRD CERTIFICATION DATE The date the patient was certified by Medicare as having End Stage Renal Disease. 90070-x 90080-x CDAR1AIS0010R010 Response Code / Numeric Units iso+ ans+ 0,1 DT DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS Information about other drugs previously prescribed for treatment of this condition with less than optimal outcomes. 1,1 0,n 90081-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS DRUG NAME This is the descriptive name of the drug previously used to treat the diagnosis. TX 1,1 90082-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS, DRUG CODE The code assigned to the drug previously used to treat the diagnosis as defined by: Representative NDC, RxNorm SCD, or RxNorm SBD. CE 1,1 NDC RxNorm SCD RxNorm SBD 90083-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS DURATION OF THERAPY Duration of previous therapy in days. NM 1,1 iso+ 90084-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS REASON PRIOR THERAPY DISCONTINUED Reason prior drug therapy was discontinued. CE 1,1 HL79040 90085-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS REASON PRIOR THERAPY DISCONTINUED, OTHER If Drug History, Prior Therapy for Diagnosis - Reason Prior Therapy Discontinued is equal to “OTH” Other, then this is required. TX 0,1 90086-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS – REASON PRIOR THERAPY DISCONTINUED, INCOMPATIBLE DRUG NAME TX 0,n NTEFF SDEFT NTCMP OTH Not or No Longer Effective Side Effects/Tolerance Not Compatible Other The descriptive name of the drug incompatible with the prior therapy. If Drug History, Prior Therapy for Diagnosis – Reason Prior Therapy Discontinued equals “NTCMP” Not Compatible, then this is required. Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page 11 November 2005 Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer 90090-x 3.2 Value CDAR1AIS0010R010 Data Type CONCURRENT THERAPY Drugs the patient is currently on, for this or other diagnoses, which may impact the requested drug. Card Response Code / Numeric Units 0,n 90091-x CONCURRENT THERAPY, DRUG NAME The descriptive name of the drug used in concurrent therapy, for this or other diagnoses, which may impact the requested drug. TX 0,1 90092-x CONCURRENT THERAPY, DRUG CODE The code assigned to the concurrent drug as defined by: Representative NDC, RxNorm SCD, or RxNorm SBD. CE 1,1 Data Type Card NDC RxNorm SCD RxNorm SBD NSAIDS - COX2 Inhibitors Value Table Table 3.2 NSAIDS - COX2 Inhibitors Value Table LOINC code Component Answer 90010-x Value PRESCRIBER INFORMATION Information about the practitioner prescribing the drug. 1,1 90011-x PRESCRIBER INFORMATION, NAME This is the name of the practitioner prescribing the drug. PN 1,1 90012-x PRESCRIBER INFORMATION, IDENTIER This may be repeated to convey multiple identifiers such as the National Provider Identifier (NPI), Drug Enforcement Act number (DEA), Special DEA number, HCIdea Number or proprietary provider identifier. CX 1,n Note: If the provider is a covered entity under HIPAA and the NPI is mandated for use, the NPI must be sent as one of the identifiers and the proprietary provider identifier must not be used. 90013-x PRESCRIBER INFORMATION, SPECIALTY TAXONOMY CODE This is the Taxonomy code that represents the medical specialty of the prescriber. 90020-x 90030-x Page 12 November 2005 NPI DEA HCIdea Proprietary Provider ID See note at left. CE PRESCRIBER CONTACT INFORMATION Contact information for the individual prescribing the drug. 1,1 PTX 0,1 90021-x PRESCRIBER CONTACT INFORMATION, PHONE NUMBER This is the phone number of the individual prescribing the drug. TX 1,1 90022-x PRESCRIBER CONTACT INFORMATION, FAX NUMBER This is the fax number of the individual prescribing the drug. TX 0,1 DRUG PRESCRIBED This is information about the drug requested in the prior authorization. 90031-x DRUG PRESCRIBED, NAME This is the descriptive name of the drug prescribed. Response Code / Numeric Units 1,1 TX 1,1 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value CDAR1AIS0010R010 Data Type Card 90032-x DRUG PRESCRIBED, DRUG CODE This is the code identifier for the drug prescribed as defined by Representative NDC, Rx Norm SCD, or RxNorm SBD. CE 1,1 NDC RxNorm SCD RxNorm SBD 90033-x DRUG PRESCRIBED, THERAPY TYPE This is used to convey the historical use of the prescribed drug as part of the patient’s therapy. CE 1,1 HL79038 0,1 HL70136 INTRQ CNTRQ RPLRQ ADDRQ Response Code / Numeric Units Initial Therapy Continued Therapy Replacement Therapy Add on Therapy 90034-x DRUG PRESCRIBED, SELF ADMINISTERED INDICATOR This indicator defines if the drug can be self administered. N No Y Yes 90100-2 NSAIDS-COX2 INHIBITORS, RELATED DIAGNOSIS Diagnosis information related to the prescribed drug. 90100-2 NSAIDS-COX2 INHIBITORS, RELATED DIAGNOSIS This is the related diagnosis of the patient for which the drug is a prescribed therapy. 1,1 CE 1,1 IC9 IC10 Note: Prior to U.S. adoption of ICD-10-CM, use ICD-9-CM in the U.S. domain. After adoption as the standard for defining diagnoses in the US, use only ICD-10-CM for requests in the US. 90080-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS Information about other drugs previously prescribed for treatment of this condition with less than optimal outcomes. 0,n 90081-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS DRUG NAME This is the descriptive name of the drug previously used to treat the diagnosis. TX 1,1 90082-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS DRUG CODE The code assigned to the drug previously used to treat the diagnosis as defined by: Representative NDC, RxNorm SCD, or RxNorm SBD. CE 1,1 NDC RxNorm SCD RxNorm SBD 90083-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS, DURATION OF THERAPY Duration of previous therapy in days. NM 1,1 iso+ 90084-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS, REASON PRIOR THERAPY DISCONTINUED Reason prior drug therapy was discontinued. CE 1,1 HL79040 NTEFF SDEFT NTCMP OTH Not or No Longer Effective Side Effects/Tolerance Not Compatible Other Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page 13 November 2005 Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer 90090-x 90110-x Value CDAR1AIS0010R010 Data Type Card 90085-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS REASON PRIOR THERAPY DISCONTINUED, OTHER Description of the other reason for discontinued therapy. If Drug History, Prior Therapy for Diagnosis - Reason Prior Therapy Discontinued equals "OTH" Other, then this is required. TX 0,1 90086-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS – REASON PRIOR THERAPY DISCONTINUED, INCOMPATIBLE DRUG NAME The descriptive name of the drug incompatible with the prior therapy. If Drug History, Prior Therapy for Diagnosis – Reason Prior Therapy Discontinued equals “NTCMP” Not Compatible, then this is required. TX 0,n CONCURRENT THERAPY Drugs the patient is currently on, for this or other diagnoses, which may impact the requested drug. 0,n 90091-x CONCURRENT THERAPY, DRUG NAME The descriptive name of the drug used in concurrent therapy, for this or other diagnoses, which may impact the requested drug. TX 0,1 90092-x CONCURRENT THERAPY, DRUG CODE The code assigned to the concurrent drug as defined by: Representative NDC, RxNorm SCD, or RxNorm SBD CE 1,1 NSAIDS/PPI RELATED CONCURRENT THERAPY NSAID/PPI related drugs being used concurrently with the requested drug. 90111-x NSAIDS/PPI RELATED CONCURRENT THERAPY, TYPE Concurrent NSAIDS/PPI related drug therapies being used for treatment of this or other conditions. Response Code / Numeric Units NDC RxNorm SCD RxNorm SBD 0,1 CE 1,1 HL79041 90112-x NSAIDS/PPI RELATED CONCURRENT THERAPY, OTHER TYPE The descriptive name of the NSAIDS/PPI related drug(s) used in concurrent therapy. Required when NSAIDS/PPI Related Concurrent Therapy, Type equals “OTH” Other. NSAID USE Extended NSAID use and associated problems. TX 0,1 90121-2 NSAID USE, DURATION The length of time NSAID use is or has been required. CE 1,1 HL79042 CE 1,1 HL79043 See section 5 for the list of valid codes. 90120-x 1,1 G21 NSAID use greater than 21 days L21 NSAID use less than 21 days 90122-2 NSAID USE, INDUCED GI RISK FACTORS Indicator of whether gastrointestinal risk factors are/have been induced by NSAID use. Y Yes N No U Unknown Page 14 November 2005 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment 3.3 CDAR1AIS0010R010 Growth Hormone (GH) Value Table Table 3.3 Growth Hormone Value Table LOINC code Component Answer 90010-x Value Data Type PRESCRIBER INFORMATION Information about the practitioner prescribing the drug. Card 1,1 90011-x PRESCRIBER INFORMATION, NAME This is the name of the practitioner prescribing the drug. PN 1,1 90012-x PRESCRIBER INFORMATION, IDENTIER This may be repeated to convey multiple identifications such as the National Provider Identifier (NPI0, the Drug Enforcement Act (DEA) number, Special DEA number, HCIdea number or proprietary identifier. CX 1,n Note: If the provider is a covered entity under HIPAA and the NPI is mandated for use, the NPI must be sent as one of the identifiers and the legacy provider identifier must not be used. 90013-x PRESCRIBER INFORMATION, SPECIALITY TAXONOMY CODE This is the Taxonomy code that identifies the medical specialty of the prescriber 90020-x 90030-x NPI DEA HCIdea Proprietary Provider ID See note at left. CE PRESCRIBER CONTACT INFORMATION Contact information for the individual prescribing the drug. 1,1 PTX 0,1 90021-x PRESCRIBER CONTACT INFORMATION, PHONE NUMBER The phone number of the individual prescribing the drug. TX 1,1 90023-x PRESCRIBER CONTACT INFORMATION, FAX NUMBER The fax number of the individual prescribing the drug. TX 0,1 DRUG PRESCRIBED This is information about the drug requested in the prior authorization. 1,1 90031-x DRUG PRESCRIBED, NAME This is the descriptive name of the drug prescribed. TX 1,1 90032-x DRUG PRESCRIBED, DRUG CODE This is the code identifier for the drug prescribed as defined by: Representative NDC, RxNorm SCD or RxNorm SBD CE 1,1 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Response Code / Numeric Units NDC RxNorm SCD RxNorm SBD Page 15 November 2005 Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value 90033-x DRUG PRESCRIBED, THERAPY TYPE This is used to convey the historical use of the prescribed drug as part of the patient's therapy. INTRQ CNTRQ RPLRQ ADDRQ CDAR1AIS0010R010 Data Type Card Response Code / Numeric Units CE 1,1 HL79038 0,1 HL70136 Initial Therapy Continued Therapy Replacement Therapy Add on Therapy 90034-x DRUG PRESCRIBED, SELF ADMINISTERED INDICATOR This indicator defines if the drug can be self administered. N No Y Yes 90130-3 GH, RELATED DIAGNOSIS This is the related diagnosis of the patient for which the drug is a prescribed therapy. 1,1 Note: Prior to U.S. adoption of ICD-10-CM, use ICD-9-CM in the U.S. domain. After adoption as the standard for defining diagnoses in the US, use only ICD-10-CM for requests in the US. 90130-3 90140-3 CE RADIOLOGICAL DIAGNOSIS CONFIRMATION INFORMATION Diagnostic procedures and criteria confirming the diagnosis and level of treatment need. 90141-3 RADIOLOGY DIAGNOSIS CONFIRMATION INFORMATION, STUDY TYPE These are the radiological studies used to confirm the diagnosis. Epiphyseal status or bone age is required for childhood growth hormone deficiency.. Page 16 November 2005 IC9 IC10 0,n CE 1,1 90142-3 RADIOLOGICAL DIAGNOSIS CONFIRMATION INFORMATION, STUDY RESULT Result of the radiological study performed. Required when diagnosis is confirmed by radiological study. TX 1,1 90143-3 RADIOLOGICAL DIAGNOSIS CONFIRMATION INFORMATION, STUDY DATE Date the radiological study performed. Required when diagnosis confirmed by radiological study. DT 1,1 BAE BDY MRI ESX 90150-3 1,1 HL79044 Bone Age Bone Density MRI X-Ray to Determine Epiphyseal Status LABORATORY DIAGNOSIS CONFIRMATION INFORMATION Diagnostic procedures and criteria confirming the diagnosis and level of treatment need. 0,n Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value CDAR1AIS0010R010 Data Type Card CE 1,n 90152-3 LABORATORY DIAGNOSIS CONFIRMATION INFORMATION, OTHER STUDY/TEST NAME This is used to convey the name of the other test used to confirm GHD. It is required when Diagnosis Confirmation Information Laboratory Confirmation equals "OTH" Other. TX 0,1 90153-3 LABORATORY DIAGNOSIS CONFIRMATION INFORMATION, STUDY/TEST RESULT This is the result of laboratory study used to confirm the diagnosis. NM 1,1 90154-3 LABORATORY DIAGNOSIS CONFIRMATION INFORMATION, STUDY/TEST DATE This is the date that the test confirming the diagnosis of GHD was performed. DT 1,1 90151-3 LABORATORY DIAGNOSIS CONFIRMATION INFORMATION, STUDY/TEST These are laboratory studies used to confirm Growth Hormone Deficiency/Dysfunction. Response Code / Numeric Units HL79045 See section 5 for a list of valid codes. 90160-3 GH, PATIENT HISTORY INFORMATION Patient history related to the prescribed drug. 90161-3 GH, PATIENT HISTORY INFORMATION – DOCUMENTED ONSET Documented onset of hypothalamic pituitary disease or GH deficiency/dysfunction. iso+ ans+ 1,1 CE 0,1 HL79046 CE 0,n HL79047 CE 1,1 HL79048 DT 0,1 AO Adult Onset CO Childhood Onset UO Unknown Onset 90162-3 GH, PATIENT HISTORY INFORMATION – HYPOTHALMIC PITUITARY DISEASE INDUCED BY This describes conditions and/or treatments leading to HPD. PTT IRR SUG HMN TRA Pituitary Tumor Irradiation Surgery Hormone Dysfunction or Therapy Trauma 90163-3 GH, PATIENT HISTORY INFORMATION – GHD TREATMENT STATUS This describes the treatment status, i.e., whether GH Therapy has been attempted in the past, is ongoing or is just begin. See section 5 for the list of valid codes. 90164-3 GROWTH HORMONE, PATIENT HISTORY INFORMATION – GHD TREATMENT DATE This is the date the current/most current GH treatment initiated/to be initiated. 90170-3 GROWTH HORMONE DEFICIENCY (GHD) CHILDHOOD INFORMATION Information about growth hormone deficiency in childhood. Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard 0,1 Page 17 November 2005 Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value 90171-3 GHD CHILDHOOD INFORMATION, SMALL FOR GESTATIONAL AGE INDICATOR This conveys information about the size of the child at birth, if known. CDAR1AIS0010R010 Data Type Card Response Code / Numeric Units CE 0,1 HL70136 CE 1,1 HL79049 CE 1,1 HL70136 N No Y Yes 90172-3 GHD CHILDHOOD INFORMATION, PUBERTY STATUS This information describes the status of the child relative to the onset of puberty if known. BP Pre-pubertal AP Post Pubertal PS Pubertal 90173-3 GHD CHILDHOOD INFORMATION, THERAPY BY PEDIATRIC ENDOCRINOLOGIST OR NEPHROLOGIST INDICATOR This conveys whether therapeutic intervention for the treatment of childhood GHD is recommended and managed by a Pediatric Endocrinologist or Nephrologists. N No Y Yes 90180-3 GH DYSFUNCTION ADULT INFORMATION This conveys information about Adult GH Dysfunction related to factors other than endocrine disorders 90181-3 GH DYSFUNCTION ADULT INFORMATION, SECONDARY CAUSES This conveys information about Adult GH Dysfunction related to factors other than endocrine disorders. A O D OTH CE 1,n TX 0,1 HL79050 Age Obesity Depression Other 90182-3 GHD DYSFUNCTION ADULT INFORMATION, OTHER SECONDARY CAUSES Description of the other causes of adult GH dysfunction. Required when GH Dysfunction Adult, Secondary Causes equals "OTH" other. 90190-3 0,1 WASTING SYNDROME INFORMATION This provides information about the patient's concurrent Wasting Syndrome 90191-3 WASTING SYNDROME INFORMATION, OCCURANCE INDICATOR This conveys whether the patient has a Wasting Syndrome in addition to the GHD. 1,1 CE 1,1 HL70136 N No Y Yes Page 18 November 2005 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value 90192-3 WASTING SYNDROME INFORMATION, WEIGHT LOSS EQUAL TO OR GREATER THAN 10% This conveys whether the patient has experienced unintentional weight loss equal to or greater than 10% of body mass. CDAR1AIS0010R010 Data Type Card Response Code / Numeric Units CE 0,1 HL70136 CE 0,1 HL70136 CE 0,1 HL70136 N No Y Yes 90193-3 WASTING SYNDROME INFORMATION, DUE TO TREATABLE CONDITION INDICATOR This defines whether the Wasting Syndrome is due to a treatable condition, e.g. an autoimmune disorder. N No Y Yes 90194-3 WASTING SYNDROME INFORMATION, TREATABLE CONDITION STATUS INDICATOR This indicates whether the treatable condition that is precipitating the Wasting Syndrome is being treated. Required if answer to Wasting Syndrome Information, Due to Treatable Condition Indicator equals "Y" Yes. N No Y Yes 90200-3 NUTRITIONAL INFORMATION The information in this section is used to convey whether the nutritional intake, both quantity and variety, is a contributory factor in the GHD. 90201-3 NUTRITIONAL INFORMATION, ASSESSMENT INDICATOR This conveys whether there has been an assessment of the patient's diet and nutritional status. Information on nutritional assessment is required if patient has Wasting Syndrome. 0,1 CE 0,1 90202-3 NUTRITIONAL INFORMATION, ASSESSMENT DATE This is the date of scheduled or completed nutritional assessment. DT 1,1 90203-3 NUTRITIONAL INFORMATION, CONCURRENT THERAPY INDICATOR This is used to convey whether the patient is receiving nutritional counseling and treatment. CE 0,1 HL79051 CMP Completed PLD Planned HL70136 N No Y Yes 90210-3 LABORATORY GH STIMULATION Provocative growth hormone stimulation, a minimum of 2 tests required. 90211-3 LABORATORY GH STIMULATION, AGENT NAME This is the name of the stimulation agent used to induce GH release in the GH stimulation test. Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard 1,n TX 1,1 Page 19 November 2005 Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer 90220-3 Value CDAR1AIS0010R010 Data Type Card 90212-3 LABORATORY GH STIMULATION, PEAK VALUES This reports the peak values of GH activity achieved with provocative stimulation by named agent. NM 1,n 90213-3 LABORATORY GH STIMULATION, DATE This is the date GH Stimulation testing was performed. DT 1,1 PHYSICAL FINDINGS, PATIENT HEIGHT This is used to report the height of the patient as measured at named intervals. 90221-3 PHYSICAL FINDINGS, PATIENT HEIGHT AT BIRTH This is the patient's height at birth or in the neonatal period. Response Code / Numeric Units iso+ ans+ 0,1 NM 0,1 iso+ ans+ NM 1,1 iso+ ans+ 90223-3 PHYSICAL FINDINGS, CURRENT PATIENT HEIGHT DATE OF MEASUREMENT This is the date that the current height measured DT 1,1 90224-3 PHYSICAL FINDINGS, BASELINE PATIENT HEIGHT This is the baseline height measured at least six months prior to request for GH therapy. It is used for assessing growth rate before and after GH therapy NM 1,1 90225-3 PHYSICAL FINDINGS, BASELINE PATIENT HEIGHT DATE OF MEASUREMENT This the date the baseline height was measured. DT 1,1 90226-3 PHYSICAL FINDINGS – PATIENT HEIGHT AT ONSET OF TREATMENT This is the patient height as measured immediately prior to treatment initiation. Required if Treatment has been initiated. NM 0,1 90227-3 PHYSICAL FINDINGS – PATIENT HEIGHT AT ONSET OF TREATMENT – DATE OF MEASUREMENT This is the date of measurement at or immediately prior to onset of treatment. Required if treatment has been initiated. DT 0,1 90228-3 PHYSICAL FINDINGS, PATIENT HEIGHT AT LAST RENEWAL This is the patient height as measured when GH therapy last requested. NM 0,1 Height will be reported in iso+ units of either cm (centimeters) or in (inches). 90222-3 PHYSICAL FINDINGS, CURRENT PATIENT HEIGHT This is the patient's height at the time of the request. Height will be reported in iso+ units of either cm (centimeters) or in (inches). iso+ ans+ Height will be reported in iso+ units of either cm (centimeters) or in (inches). iso+ ans+ Height will be reported in iso+ units of either cm (centimeters) or in (inches). iso+ ans+ Height will be reported in iso+ units of either cm (centimeters) or in (inches). Page 20 November 2005 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value 90229-3 PHYSICAL FINDINGS, PATIENT HEIGHT AT LAST RENEWAL, DATE OF MEASUREMENT This is the date the height was measured for the last request for renewal. 90230-3 CDAR1AIS0010R010 Data Type Card DT 0,1 PHYSICAL FINDINGS, PATIENT WEIGHT Weight of the patient at given intervals. 90231-3 PHYSICAL FINDINGS – PATIENT WEIGHT AT BIRTH This is the weight of the patient at birth. Response Code / Numeric Units 0,1 NM 0,1 iso+ ans+ NM 1,1 iso+ ans+ 90233-3 PHYSICAL FINDINGS, CURRENT PATIENT WEIGHT DATE OF MEASUREMENT This is the date the current weight was measured. DT 1,1 90234-3 PHYSICAL FINDINGS, BASELINE PATIENT WEIGHT Baseline weight, at least six months prior to request for GH therapy. NM 1,1 90235-3 PHYSICAL FINDINGS, BASELINE PATIENT WEIGHT DATE OF MEASUREMENT This is the date baseline weight was measured DT 1,1 90236-3 PHYSICAL FINDINGS, PATIENT WEIGHT AT ONSET OF TREATMENT This is the patient's weight as measured when treatment initiated. Required if treatment has been initiated. NM 0,1 90237-3 PHYSICAL FINDINGS, PATIENT WEIGHT AT ONSET OF TREATMENT - DATE OF MEASUREMENT This is the patient weight as measured at or immediately prior to the onset of treatment. Required if treatment has been initiated. DT 0,1 90238-3 PHYSICAL FINDINGS, PATIENT WEIGHT AT LAST RENEWAL This is the patient weight as measured when GH therapy was last requested. NM 0,1 DT 0,1 Weight will be reported as either iso+ units of gm (grams) or kg (kilograms) or ans+ units of oz (ounces) or lb (pounds). 90232-3 PHYSICAL FINDINGS, CURRENT PATIENT WEIGHT This is the weight of the patient as of the time of this request. Weight will be reported as either iso+ units of gm (grams) or kg (kilograms) or ans+ units of oz (ounces) or lb (pounds). iso+ ans+ Weight will be reported as either iso+ units of gm (grams) or kg (kilograms) or ans+ units of oz (ounces) or lb (pounds). iso+ ans+ Weight will be reported as either iso+ units of gm (grams) or kg (kilograms) or ans+ units of oz (ounces) or lb (pounds). iso+ ans+ Weight will be reported as either iso+ units of gm (grams) or kg (kilograms) or ans+ units of oz (ounces) or lb (pounds). 90239-3 PHYSICAL FINDINGS, PATIENT WEIGHT LAST RENEWAL - DATE OF MEASUREMENT This is the date the patient weight was measured for the last renewal request. Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page 21 November 2005 Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer 90240-3 Value CDAR1AIS0010R010 Data Type PATIENT BODY MASS INDEX This is information regarding the patient's body mass index. 90241-3 PATIENT BODY MASS INDEX, CURRENT This the patient's Body Mass Index (BMI) as calculated at the time of the request Card Response Code / Numeric Units 0,1 NM 1,1 iso+ NM 0,1 iso+ Must be reported in iso+ units of IU (international units). 90242-3 PATIENT BODY MASS INDEX, AT ONSET OF TREATMENT This is the Body Mass Index as calculated at the time of onset of GH treatment. Must be reported in iso+ units of IU (international units). 90250-3 PARENTAL HEIGHT Parental height information. May be required for coverage of childhood GH therapy. 90251-3 PARENTAL HEIGHT, AVAILABILITY INDICATOR This reflects the availability of parental height information. MK FK BK BU 0,1 CE 1,1 HL79052 NM 0,1 iso+ ans+ NM 0,1 iso+ ans+ Mother Known Father Known Both Known Both Unknown 90252-3 PARENTAL HEIGHT, MOTHER Mother's height if known. Required if the Parental Height, Availability Indicator equals "MK" mother known or "BK" both known. Height will be reported in iso+ units of either cm (centimeters) or in (inches). 90253-3 PARENTAL HEIGHT, FATHER Father's height if known. Required if the Parental Height, Availability Indicator equals "FK" father known or "BK" both known. Height will be reported in iso+ units of either cm (centimeters) or in (inches). 90080-x Page 22 November 2005 DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS Information about other drugs previously prescribed for treatment of this condition with less than optimal outcomes. 0,n 90081-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS DRUG NAME This is the descriptive name of the drug previously used to treat the diagnosis. TX 1,1 90082-x DRUG HISTORY - PRIOR THERAPY FOR DIAGNOSIS, DRUG CODE The code assigned to the drug previously used to treat the diagnosis as defined by: Representative NDC, RxNorm SCD or RxNorm SBD CE 1,1 NDC RxNorm SCD RxNorm SBD Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value Data Type Card 90083-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS DURATION OF THERAPY Duration of previous therapy in days. NM 1,1 iso+ 90084-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS REASON PRIOR THERAPY DISCONTINUED This is the reason that prior drug therapy was discontinued. CE 1,1 HL79040 90085-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS NAME OF INCOMPATIBLE DRUG(S) The descriptive name of the drug Incompatible with the prior therapy. If Drug History, Prior Therapy for Diagnosis - Reason Prior Therapy Discontinued equals "NTCMP" Not Compatible, then this is required. TX 0,n 90086-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS REASON(S) PRIOR THERAPY DISCONTINUED, OTHER Description of the other reason for discontinued therapy. If Drug History, Prior Therapy for Diagnosis - Reason Prior Therapy Discontinued equals "OTH" Other, then this is required. TX 0,1 NTEFF SDEFT NTCMP OTH 90090-x Response Code / Numeric Units Not or No Longer Effective Side Effects/Tolerance Not Compatible Other CONCURRENT THERAPY Drugs the patient is currently on, for this or other diagnoses, which might impact the requested drug. 90091-x CONCURRENT THERAPY, DRUG NAME The descriptive name of the drug(s) used in concurrent therapy, for this or other diagnoses, which may impact the requested drug. 90092-x CONCURRENT THERAPY, DRUG CODE The code assigned to the concurrent drug as defined by: Representative NDC, RxNorm SCD, or RxNorm SBD 3.4 CDAR1AIS0010R010 0,n TX 0,1 CE 1,1 Data Type Card NDC RxNorm SCD RxNorm SBD Proton Pump Inhibitors (PPI) Value Table Table 3.4 Proton Pump Inhibitors Value Table LOINC code Component Answer 90010-x Value PRESCRIBER INFORMATION Information about the practitioner prescribing the drug. 90011-x PRESCRIBER INFORMATION, NAME This is the name of the practitioner prescribing the drug. Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Response Code / Numeric Units 1,1 PN 1,1 Page 23 November 2005 Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value 90012-x PRESCRIBER INFORMATION, IDENTIER This may be repeated to convey multiple identifiers such as the DEA number, NPI, HCIdea Number or proprietary provider identifier. CDAR1AIS0010R010 Data Type Card CX 1,n Note: If the provider is a covered entity under HIPAA and the NPI is mandated for use, the NPI must be sent as one of the identifiers and the legacy provider identifier must not be used. 90013-x PRESCRIBER INFORMATION, SPECIALITY TAXONOMY CODE This is the Taxonomy code that identifies the medical specialty of the prescriber 90020-x 90030-x Page 24 November 2005 Response Code / Numeric Units NPI DEA HCIdea Proprietary Provider ID See note at left. CE PRESCRIBER CONTACT INFORMATION Contact information for the individual prescribing the drug. 1,1 PTX 0,1 90021-x PRESCRIBER CONTACT INFORMATION, PHONE NUMBER The phone number of the individual prescribing the drug. TX 1,1 90022-x PRESCRIBER CONTACT INFORMATION, FAX NUMBER The fax number of the individual prescribing the drug. TX 0,1 DRUG PRESCRIBED This is information about the drug requested in the prior authorization. 1,1 90031-x DRUG PRESCRIBED, NAME This is the descriptive name of the drug prescribed. TX 1,1 90032-x DRUG PRESCRIBED, DRUG CODE This is the code identifier for the drug prescribed as defined by: Representative NDC, RxNorm SCD or RxNorm SBD . CE 1,1 NDC RxNorm SCD RxNorm SBD Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value 90033-x DRUG PRESCRIBED, THERAPY TYPE This is used to convey the historical use of the prescribed drug as part of the patient's therapy. INTRQ CNTRQ RPLRQ ADDRQ CDAR1AIS0010R010 Data Type Card Response Code / Numeric Units CE 1,1 HL79038 CE 0,1 HL70136 Initial Therapy Continued Therapy Replacement Therapy Add on Therapy 90034-x DRUG PRESCRIBED, SELF ADMINISTERED INDICATOR N No Y Yes 90260-4 PPI, RELATED DIAGNOSIS This is the related diagnosis of the patient for which the drug is a prescribed therapy. 1,1 Note: Prior to U.S. adoption of ICD-10-CM, use ICD-9-CM in the U.S. domain. After adoption as the standard for defining diagnoses in the US, use only ICD-10-CM for requests in the US. 90260-4 90270-4 CE DIAGNOSIS CONFIRMATION AND LEVEL OF TREATMENT NEEDED Diagnosis procedures and criteria confirming the diagnosis and level of treatment needed. 90271-4 DIAGNOSIS CONFIRMATION AND LEVEL OF TREATMENT NEEDED, PROCEDURE EMPLOYED These are procedures performed to establish the diagnosis. 1,1 IC9 IC10 1,1 CE 1,n HL79053 CE 0,1 HL79054 BMS Barium Studies EGD Endoscopy BIO Biopsy 90272-4 DIAGNOSIS CONFIRMATION AND LEVEL OF TREATMENT NEEDED, GERD BY ENDOSCOPY TYPE This is the level of severity of GERD as confirmed by endoscopy. Required when GERD confirmed by endoscopy. See section 5 for the list of valid codes. 90280-4 PPI, PATIENT HISTORY - STRICTURE PRESENT This conveys information that esophageal stricture is present with the related diagnosis. Required if the related diagnosis is "Barrett Esophagus". 90280-4 0,1 CE 1,1 HL70136 N No Y Yes 90080-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS Information about other drugs previously prescribed for treatment of this condition with less than optimal outcomes. Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard 0,n Page 25 November 2005 Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value Data Type Card 90081-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS DRUG NAME This is the descriptive name of the drug previously used to treat the diagnosis. TX 1,1 90082-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS DRUG CODE The code assigned to the drug previously used to treat the diagnosis as defined by: Representative NDC, RxNorm SCD or RxNorm SBD CE 1,1 NDC RxNorm SCD RxNorm SBD 90083-x DRUG HISTORY,PRIOR THERAPY FOR DIAGNOSIS DURATION OF THERAPY Duration of previous therapy in days. NM 1,1 iso+ 90084-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS REASON PRIOR THERAPY DISCONTINUED This is the reason that the prior drug therapy was discontinued. CE 1,1 HL79040 TX 0,1 TX 0,n NTEFF SDEFT NTCMP OTH 90110-x Response Code / Numeric Units Not or No Longer Effective Side Effects/Tolerance Not Compatible Other 90085-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS, REASON(S) PRIOR THERAPY DISCONTINUED, OTHER Description of the other reason for discontinued therapy. If Drug History, Prior Therapy for Diagnosis - Reason Prior Therapy Discontinued equals "OTH" Other, then this is required. 90086-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS INCOMPATIBLE DRUG NAME The descriptive name of the drug incompatible with the prior therapy. If Drug History, Prior Therapy for Diagnosis – Reason Therapy Discontinued equals "NTCMP" Not Compatible, then this is required. 90090-x CDAR1AIS0010R010 CONCURRENT THERAPY Drugs the patient is currently on, for this or other diagnoses, which might impact the requested drug. 0,n 90091-x CONCURRENT THERAPY, DRUG NAME The descriptive name of the drug(s) used in concurrent therapy, for this or other diagnoses, which may impact the requested drug. TX 0,1 90092-x CONCURRENT THERAPY, DRUG CODE The code assigned to the ordered drug as defined by: Representative NDC, RxNorm SCD, or RxNorm SBD CE 1,1 NSAIDS/PPI RELATED CONCURRENT THERAPY NSAID/PPI related drugs being used concurrently with the requested drug. 90111-x NSAIDS/PPI RELATEDE, CONCURRENT THERAPY, TYPE Concurrent NSAIDS/PPI related drug therapies being used for treatment of this or other conditions. NDC RxNorm SCD RxNorm SBD 0,1 CE 1,1 HL79041 See section 5 for the list of valid codes. Page 26 November 2005 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer 90290-4 Value CDAR1AIS0010R010 Data Type Card Response Code / Numeric Units 90112-x NSAIDS/PPI RELATED CONCURRENT THERAPY, OTHER TYPE The descriptive name of the NSAIDS/PPI related drug(s) used in concurrent therapy. Required when NSAIDS/PPI Related Concurrent Therapy, Type equals “OTH” Other. H-PYLORI INFORMATION H-Pylori status in relation to the need for PPI. TX 0,1 90291-4 H-PYLORI INFORMATION, STATUS This is the documented H-Pylori status of the patient. CE 1,1 HL79056 CE 1,n HL79057 TX 0,1 0,1 PS Positive NE Negative 90292-4 H-PYLORI INFORMATION, CONFIRMED BY This conveys the method used to confirm H-Pylori. See section 5 for the list of valid codes. 90293-4 H-PYLORI INFORMATION, CONFIRMED BY - OTHER Description of the method used to confirm the presence of HPylori, required when the response to H-Pylori Information, Confirmed by equals "OTH" Other. 90300-4 H-PYLORI TREATMENT H-Pylori treated or being treated. 90301-4 H-PYLORI TREATMENT, CDA PROTOCOL INDICATOR This conveys whether the treatment of H-Pylori is/was/will be done in compliance with CDA protocols. 0,1 CE 1,1 HL70136 N No Y Yes 3.5 90302-4 H-PYLORI TREATMENT, START DATE This is the date that treatment of H-Pylori began or is to begin. DT 0,1 90303-4 H-PYLORI TREATMENT, END DATE Date treatment of H-Pylori was or is expected to be completed. DT 0,1 Data Type Card Erectile Dysfunction (ED) Agents Value Table Table 3.5 Erectile Dysfunction Agents Value Table LOINC code Component Answer 90010-x Value PRESCRIBER INFORMATION Information about the practitioner prescribing the drug. 90011-x PRESCRIBER INFORMATION, NAME This is the name of the practitioner prescribing the drug. Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Response Code / Numeric Units 1,1 PN 1,1 Page 27 November 2005 Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value 90012-x PRESCRIBER INFORMATION, IDENTIER This may be repeated to convey multiple identifiers such as the DEA number, NPI, HCIdea Number or proprietary provider identifier. CDAR1AIS0010R010 Data Type Card CX 1,n Note: If the provider is a covered entity under HIPAA and the NPI is mandated for use, the NPI must be sent as one of the identifiers and the legacy provider identifier must not be used. 90013-x PRESCRIBER INFORMATION, SPECIALITY TAXONOMY CODE This is the Taxonomy code that identifies the medical specialty of the prescriber. 90020-x 90030-x Page 28 November 2005 Response Code / Numeric Units NPI DEA HCIdea Proprietary Provider ID See note at left. CE PRESCRIBER CONTACT INFORMATION Contact information for the individual prescribing the drug. 1,1 PTX 0,1 90021-x PRESCRIBER CONTACT INFORMATION, PHONE NUMBER The phone number of the individual prescribing the drug. TX 1,1 90022-x PRESCRIBER CONTACT INFORMATION, FAX NUMBER The fax number of the individual prescribing the drug. TX 0,1 DRUG PRESCRIBED This is information about the drug requested in the prior authorization. 1,1 90031-x DRUG PRESCRIBED, NAME This is the descriptive name of the drug prescribed. TX 1,1 90032-x DRUG PRESCRIBED, DRUG CODE This is the code identifier for the drug prescribed as defined by: Representative NDC, RxNorm SCD or RxNorm SBD CE 1,1 NDC RxNorm SCD RxNorm SBD Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value 90033-x DRUG PRESCRIBED, THERAPY TYPE This is used to convey the historical use of the prescribed drug as part of the patient's therapy. INTRQ CNTRQ RPLRQ ADDRQ CDAR1AIS0010R010 Data Type Card Response Code / Numeric Units CE 1,1 HL79038 0,1 HL70136 Initial Therapy Continued Therapy Replacement Therapy Add on Therapy 90034-x DRUG PRESCRIBED, SELF ADMINISTERED INDICATOR This indicator defines if the drug can be self administered. N No Y Yes 90310-5 ERECTILE DYSFUNCTION, RELATED DIAGNOSIS This is the related diagnosis of the patient for which the drug is a prescribed therapy. 1,1 Note: Prior to U.S. adoption of ICD-10-CM, use ICD-9-CM in the U.S. domain. After adoption as the standard for defining diagnoses in the US, use only ICD-10-CM for requests in the US. 90310-5 90320-5 CE ED, RELATED DIAGNOSIS CONFIRMATION INFORMATION This is information about how the diagnosis was confirmed. 90321-5 ED, RELATED DIAGNOSIS CONFIRMATION – CONFIRMED BY This reports tests used to confirm the ED diagnosis 1,1 IC9 IC10 1,n CE 1,n TX 0,1 HL79057 See section 5 for the list of valid codes. 90322-5 ED, RELATED DIAGNOSIS CONFIRMATION – ED DIAGNOSIS CONFIRMED BY, OTHER This is used to convey the name of the other test used to confirm ED. It is required when Erectile Dysfunction, Patient History – ED Diagnosis Confirmed By equals "OTH" Other. 90330-5 90323-5 ED, RELATED DIAGNOSIS CONFIRMATION – RESULT This is the result of the test confirming diagnosis of ED NM 1,1 90324-5 ED, RELATED DIAGNOSIS CONFIRMATION - DATE This is the date that the test confirming diagnosis of ED was performed. DT 1,1 ED, PATIENT HISTORY INFORMATION This is information relating to the history of the patient. Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard iso+ 1,1 Page 29 November 2005 Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value 90331-5 ED, PATIENT HISTORY – PULMONARY HYPERTENSION FUNCTIONAL LEVEL Functional Level of Individual with Primary Pulmonary Hypertension, Peripheral Artery Hypertension or Pulmonary Artery Hypertension C1 C2 C3 C4 90332-5 CDAR1AIS0010R010 Data Type Card Response Code / Numeric Units CE 0,1 HL79058 CE 1,1 HL79059 CE 1,1 HL70136 CE 0,n HL79060 Class I Class II Class III Class IV ED, PATIENT HISTORY – EVALUATION TYPE COMPLETED This conveys whether the patient has been evaluated for general health or contributory factors. GH General Health Status Evaluation UC Investigation of Underlying Causes of Primary Condition NA Not applicable 90333-5 ED, PATIENT HISTORY – ED LEVEL INDICATOR This indicator defines whether the dysfunction is present 50% or more of the time in the last 6 months. Y Yes N No 90334-5 ED, PATIENT HISTORY – ED RELATED TO This is used to convey information related to other conditions resulting in ED See section 5 for the list of valid codes. 90340-5 ED, TREATMENT OF RELATED CAUSES Treatment status of conditions precipitating ED. 90341-5 ED, TREATMENT OF RELATED CAUSES – TREATMENT OF REVERSIBLE CAUSES STATUS Treatment status of conditions precipitating ED. 0,1 CE 1,1 HL79048 CE 0,1 HL79048 90343-5 ED, TREATMENT OF RELATED CAUSES – RADIATION THERAPY START DATE This is the date that radiation therapy began. It is required if radiation therapy is planned or in progress. DT 0,1 90344-5 ERECTILE DYSFUNCTION, TREATMENT OF RELATED CAUSES – RADIATION THERAPY END DATE This is the date that radiation therapy was or is expected to be completed. Required when Radiation Therapy employed for treatment. DT 0,1 See section 5 for the list of valid codes. 90342-5 ED, TREATMENT OF RELATED CAUSES – RADIATION THERAPY STATUS This is used to convey the status of Radiation Therapy, It is required if the related diagnosis is Testicular Cancer. See section 5 for the list of valid codes. Page 30 November 2005 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value CDAR1AIS0010R010 Data Type Card CE 0,1 90346-5 ED, TREATMENT OF RELATED CAUSES – SURGERY DATE This is the date that surgery was or is expected to be accomplished. Required when Surgery is employed for treatment of Testicular Cancer. DT 0,1 90347-5 ED, TREATMENT OF RELATED CAUSES – PSYCHOGENIC CAUSES OF ED TREATMENT This conveys information about whether the psychogenic components of ED can or have been treated and if so, by what method. CE 0,1 HL79061 CE 0,1 HL70136 CE 0,1 HL79062 90345-5 ED, TREATMENT OF RELATED CAUSES – SURGICAL TREATMENT INDICATOR This conveys information about whether the related condition can or has been treated with surgery. It is required if the related diagnosis is Testicular Cancer. Response Code / Numeric Units HL79051 CMP Completed PLD Planned PSY BHT OTT NOT Psychotherapy Behavior Therapy Other Therapy No Therapy 90348-5 ED, TREATMENT OF RELATED CAUSES – ED DRUG INDUCED INDICATOR This is used to convey whether the ED is secondary to drugs being taken by the patient. N No Y Yes 90349-5 ED, TREATMENT OF RELATED CAUSES – DRUG INDUCED OPTION This is used to define the options, if any, for altering the use of drug that is precipitating ED. RDU DCT CGD DCN 90080-x Reduction in Drug Use Discontinue Drug Use Change Drug Drug Cannot be Changed or Discontinued DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS Information about other drugs previously prescribed for treatment of this condition with less than optimal outcomes. 0,n 90081-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS DRUG NAME This is the descriptive name of the drug previously used to treat the diagnosis. TX 1,1 90082-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS DRUG CODE The code assigned to the drug previously used to treat the diagnosis as defined by: Representative NDC, RxNorm SCD, or RxNorm SBD CE 1,1 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard NDC RxNorm SCD RxNorm SBD Page 31 November 2005 Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value CDAR1AIS0010R010 Data Type Card 90083-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS, DURATION OF THERAPY Duration of previous therapy in days. NM 1,1 iso+ 90084-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS REASON PRIOR THERAPY DISCONTINUED Reason prior drug therapy was discontinued. CE 1,1 HL79040 90085-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS REASON PRIOR THERAPY DISCONTINUED, OTHER Description of the other reason for discontinued therapy. If Drug History, Prior Therapy for Diagnosis - Reason Prior Therapy Discontinued equals "OTH" Other, then this is required. TX 0,1 90086-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS – REASON PRIOR THERAPY DISCONTINUED, NAME OF INCOMPATIBLE DRUG(S) The descriptive name of the drug incompatible with the prior therapy. If Drug History, Prior Therapy for Diagnosis - Reason Prior Therapy Discontinued equals "NTCMP" Not Compatible, then this is required. TX 0,1 NTEFF SDEFT NTCMP OTH 90090-x Not or No Longer Effective Side Effects/Tolerance Not Compatible Other CONCURRENT THERAPY Drugs the patient is currently on, for this or other diagnoses, which might impact the requested drug. 90350-5 Response Code / Numeric Units 0,n 90091-x CONCURRENT THERAPY, DRUG NAME The descriptive name of the drug(s) used in concurrent therapy, for this or other diagnoses, which may impact the requested drug. TX 0,1 90092-x CONCURRENT THERAPY, DRUG CODE The code assigned to the concurrnt drug as defined by: Representative NDC, RxNorm SCD, or RxNorm SBD ED RELATED CONCURRENT THERAPY ED related drugs being used concurrently with the requested drug. CE 1,1 90351-5 ED RELATED CONCURRENT THERAPY, TYPE Concurrent ED related drug therapies being used for treatment of this or other conditions. CE 1,1 TX 0,1 NDC RxNorm SCD RxNorm SBD 0,1 HL79063 See section 5 for the list of valid codes. 90352-5 ED RELATED CONCURRENT THERAPY, DRUG NAME(S) The descriptive name of the ED related drug(s) used in concurrent therapy. Required when ED Related Concurrent Therapy, Type equals “OTH” Other. 3.6 Narcotic(Opioid) Agonists Value Table Table 3.6 Narcotic(Opioid) Agonists Value Table LOINC code Component Answer Page 32 November 2005 Value Data Type Card Response Code / Numeric Units Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer 90010-x Value CDAR1AIS0010R010 Data Type PRESCRIBER INFORMATION Information about the practitioner prescribing the drug. Card 1,1 90011-x PRESCRIBER INFORMATION, NAME This is the name of the practitioner prescribing the drug. PN 1,1 90012-x PRESCRIBER INFORMATION, IDENTIER This may be repeated to convey multiple identifiers such as the DEA number, NPI, HCIdea Number or proprietary provider identifier. CX 1,n Note: If the provider is a covered entity under HIPAA and the NPI is mandated for use, the NPI must be sent as one of the identifiers and the legacy provider identifier must not be used. 90013-x PRESCRIBER INFORMATION, SPECIALITY TAXONOMY CODE Taxonomy code that identifies the medical specialty of the prescriber 90020-x 90030-x NPI DEA HCIdea Proprietary Provider ID See note at left. CE PRESCRIBER CONTACT INFORMATION Contact information for the individual prescribing the drug. 1,1 PTX 0,1 90021-x PRESCRIBER CONTACT INFORMATION, PHONE NUMBER The phone number of the individual prescribing the drug. TX 1,1 90022-x PRESCRIBER CONTACT INFORMATION, FAX NUMBER The fax number of the individual prescribing the drug. TX 0,1 DRUG PRESCRIBED This is information about the drug requested in the prior authorization. 1,1 90031-x DRUG PRESCRIBED, NAME This is the descriptive name of the drug prescribed. TX 1,1 90032-x DRUG PRESCRIBED, DRUG CODE This is the code identifier for the drug prescribed as defined by: Representative NDC, RxNorm SCD or RxNorm SBD. CE 1,1 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Response Code / Numeric Units NDC RxNorm SCD RxNorm SBD Page 33 November 2005 Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value 90033-x DRUG PRESCRIBED, THERAPY TYPE This is used to convey the historical use of the prescribed drug as part of the patient’s therapy. INTRQ CNTRQ RPLRQ ADDRQ CDAR1AIS0010R010 Data Type Card Response Code / Numeric Units CE 1,1 HL79038 CE 0,1 HL70136 Initial Therapy Continued Therapy Replacement Therapy Add on Therapy 90034-x DRUG PRESCRIBED, SELF ADMINISTERED INDICATOR This indicator defines if the drug can be self administered. N No Y Yes 90360-6 NARCOTIC (OPIOID) AGONISTS, RELATED DIAGNOSIS This is the related diagnosis of the patient for which the drug is a prescribed therapy. 1,1 Note: Prior to U.S. adoption of ICD-10-CM, use ICD-9-CM in the U.S. domain. After adoption as the standard for defining diagnoses in the US, use only ICD-10-CM for requests in the US. 90360-6 90370-6 CE NARCOTIC (OPIOID) AGONISTS, PATIENT HISTORY Patient history related to the prescribed drug. 90371-6 NARCOTIC (OPIOID) AGONISTS, PATIENT HISTORY – PAIN SYNDROME SOURCE This conveys information regarding the source or type of pain the patient is experiencing. 1,1 IC9 IC10 1,1 CE 1,1 HL79064 90372-6 NARCOTIC (OPIOID) AGONISTS, PATIENT HISTORY – PAIN SYNDROME SOURCE, OTHER Description of the source of the Pain Syndrome. Required when the answer to Opioid Agonists, Patient History – Pain Syndrome Source equals “OTH”, other. TX 0,1 90373-6 NARCOTIC (OPIOID) AGONISTS, PATIENT HISTORY – PAIN SYNDROME FRENQUENCY Frequency with which pain occurs. CE 1,1 HL79065 CE 1,1 HL79066 See section 5 for the list of valid codes. CP Constant Pain ITP Intermittent Pain ICP Incidental Pain 90374-6 NARCOTIC (OPIOID) AGONISTS, PATIENT HISTORY – PAIN SYNDROME PERSISTENCE Anticipated duration/persistence of pain. AL CR CRP CPR Page 34 November 2005 Acute Limited – less than 30 Days Chronic Chronic Progressive Chronic Progressive with Escalating Opioid Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer 90380-6 Value CDAR1AIS0010R010 Data Type NARCOTIC (OPIOID) AGONISTS, COMPLICATING CONDITION INFORMATION Information about co-morbid conditions complicating or exacerbating pain management. 90381-6 NARCOTIC (OPIOID) AGONISTS, COMPLICATING CONDITIONS Co-morbid conditions complicating or exacerbating pain management. Card Response Code / Numeric Units 1,n CE 1,1 TX 0,1 HL79067 See section 5 for the list of valid codes. 90382-6 NARCOTIC (OPIOID) AGONISTS, COMPLICATING CONDITIONS, OTHER Description of co-morbid condition. Required when answer to Complicating Condition equals “OTH” Other. 90390-6 90080-x NARCOTIC (OPIOID) AGONISTS, LABORATORY INFORMATION Report of drug screens performed since last review or escalation of drug therapy. 1,n 90391-6 NARCOTIC (OPIOID) AGONISTS, LABORATORY – NAME OF TEST The name of the test used to verify the presence of the Opioid. TX 1,1 90392-6 NARCOTIC (OPIOID) AGONISTS, LABORATORY - DATE OF TEST Date test performed DT 1,1 90393-6 NARCOTIC (OPIOID) AGONISTS, LABORATORY – TEST RESULT This conveys the results of the drug screen. NM 1,1 DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS Information about other drugs previously prescribed for pain management, both opioid and non-opioid, with less than optimal outcomes. iso+ 0,n 90081-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS – DRUG NAME Name of drug previously used for pain management. TX 1,1 90082-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS – DRUG CODE The code assigned to the drug previously used to treat the diagnosis as defined by: Representative NDC, RxNorm SCD or RxNorm SBD CE 1,1 NDC RxNorm SCD RxNorm SBD 90083-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS DURATION OF THERAPY Duration of previous therapy in days. NM 1,1 iso+ Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page 35 November 2005 Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value Data Type Card CE 1,1 90085-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS REASON PRIOR THERAPY DISCONTINUED, OTHER Description of the other reason for discontinued therapy. If Drug History, Prior Therapy for Pain Management – Reason Prior Therapy Discontinued equals “OTH” Other, then this is required. TX 0,1 90086-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS – INCOMPATIBLE DRUG NAME The descriptive name of the drug Incompatible with the prior therapy. If Drug History, Prior Therapy for Diagnosis – Reason Prior Therapy Discontinued equals “NTCMP” Not Compatible, then this is required. TX 0,1 90084-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS – REASON PRIOR THERAPY DISCONTINUED This is the reason that the prior pain therapy was discontinued. NTEFF SDEFT NTCMP OTH 90090-x 90400-6 CONCURRENT THERAPY Drugs the patient is currently on, for this or other diagnoses, which might impact the requested drug. Page 36 November 2005 HL9040 0,1 90091-x CONCURRENT THERAPY, DRUG NAME The descriptive name of the drug(s) used in concurrent therapy, for this or other diagnoses, which may impact the requested drug. TX 0,1 90092-x CONCURRENT THERAPY – DRUG CODE The code assigned to the concurrent drug as defined by: Representative NDC, RxNorm SCD, or RxNorm SBD CE 1,1 NDC RxNorm SCD RxNorm SBD 0,1 OPIOID RELATED CONCURRENT PAIN THERAPY Concurrent drug therapies used in pain management. RDL HPL 24L OTL Response Code / Numeric Units Not or No Longer Effective Side Effects/Tolerance Not Compatible Other 90401-6 OPIOID RELATED CONCURRENT PAIN THERAPY, NAME Descriptive name of the Opioid and non-Opioid drugs used concurrently for pain management. 90402-6 OPIOID RELATED CONCURRENT PAIN THERAPY, DRUG CODE The code assigned to the concurrent drug as defined by: Representative NDC, RxNorm SCD, or RxNorm SBD. 90403-6 OPIOID RELATED CONCURRENT PAIN THERAPY, OPIOID LEVEL Level of concurrent Opioid therapy. 90410-6 CDAR1AIS0010R010 TX 0,1 CE 1,1 NDC RxNorm SCD RxNorm SBD CE 0,1 HL79068 Recommended Dose Level High Potency Dose Level 24 Hour High Potency Dose Level Opioid Tolerant NARCOTIC (OPIOID) AGONIST, USE FOR TREATMENT OF OPIOID ADDICTION Use of Narcotic (Opioid) Agonists for the treatment of opioid addiction. 0,1 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value CDAR1AIS0010R010 Data Type Card CE 1,1 90412-6 NARCOTIC (OPIOID) AGONIST, USE FOR TREATMENT OF OPIOID ADDICTION - DATE OPIOID DISCONTINUED Date that the object drug of the addiction was discontinued or is planned to be discontinued DT 1,1 90413-6 NARCOTIC (OPIOID) AGONIST, USE FOR TREATMENT OF OPIOID ADDICTION - INDUCTION THERAPY DATE INITIATED Date induction therapy initiated or to be initiated. DT 1,1 90414-6 NARCOTIC (OPIOID) AGONIST USE FOR TREATMENT OF OPIOID ADDICTION, INDUCTION THERAPY – DATE ORAL INITIATED Date to switch to oral medication if induction therapy initiated with injectable drug. DT 0,1 90415-6 NARCOTIC (OPIOID) AGONIST USE FOR TREATMENT OF OPIOID ADDICTION - DURATION Planned length of time on agonist treatment. NM 1,1 90416-6 NARCOTIC (OPIOID) AGONIST, USE FOR TREATMENT OF OPIOID ADDICTION - DOSE TITRATION Description of the titration plan or the agonist including time line. TX 1,1 90411-6 NARCOTIC (OPIOID) AGONIST, USE FOR TREATMENT OF OPIOID ADDICTION - OPIOID DISCONTINUED This conveys whether the addicted drug has been discontinued. Response Code / Numeric Units HL70136 N No Y Yes 3.7 iso+ Imidazole - Related Antifungals Value Table Table 3.7 Imidazole - Related Antifungals Value Table LOINC code Component Answer 90010-x Value Data Type PRESCRIBER INFORMATION Information about the practitioner prescribing the drug. Card 1,1 90011-x PRESCRIBER INFORMATION, NAME This is the name of the practitioner prescribing the drug. PN 1,1 90012-x PRESCRIBER INFORMATION, IDENTIER This may be repeated to convey multiple identifications such as the National Provider Identifier [NPI], the Drug Enforcement Act [DEA] number, Special DEA number, HCIdea number or proprietary identifier. CX 1,n Note: If the provider is a covered entity under HIPAA and the NPI is mandated for use, the NPI must be sent as one of the identifiers and the legacy provider identifier must not be used. 90013-x PRESCRIBER INFORMATION, SPECIALTY TAXONOMY CODE Taxonomy code that identifies the medical specialty of the prescriber Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Response Code / Numeric Units NPI DEA HCIdea Proprietary Provider ID See note at left. CE 1,1 PTX Page 37 November 2005 Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer 90020-x 90030-x Page 38 November 2005 Value CDAR1AIS0010R010 Data Type PRESCRIBER CONTACT INFORMATION Contact information for the individual prescribing the drug. Card Response Code / Numeric Units 0,1 90021-x PRESCRIBER CONTACT INFORMATION, PHONE NUMBER The phone number of the individual prescribing the drug. TX 1,1 90022-x PRESCRIBER CONTACT INFORMATION, FAX NUMBER The fax number of the individual prescribing the drug. TX 0,1 DRUG PRESCRIBED This is information about the drug requested in the prior authorization. 1,1 90031-x DRUG PRESCRIBED, NAME This is the descriptive name of the drug prescribed. TX 1,1 90032-x DRUG PRESCRIBED, DRUG CODE This is the code identifier for the drug prescribed as defined by: Representative NDC, RxNorm SCD or RxNorm SBD CE 1,1 NDC RxNorm SCD RxNorm SBD Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value 90033-x DRUG PRESCRIBED, THERAPY TYPE This is used to convey the historical use of the prescribed drug as part of the patient's therapy. INTRQ CNTRQ RPLRQ ADDRQ CDAR1AIS0010R010 Data Type Card Response Code / Numeric Units CE 1,1 HL79038 CE 0,1 HL70136 Initial Therapy Continued Therapy Replacement Therapy Add on Therapy 90034-x DRUG PRESCRIBED, SELF ADMINISTERED INDICATOR This indicator defines if the drug can be self administered. N No Y Yes 90420-7 DRUG PRESCRIBED, TOPICAL THERAPY Information about why a topical therapy was prescribed. 90421-7 DRUG PRESCRIBED, TOPICAL THERAPY - REASON The reason a topical therapy was prescribed. 0,1 CE 1,1 TX 0,1 HL79069 UTS Unable to swallow HDS Hepatic Dysfunction OTH Other (If used, then Topical Therapy Reason – Other must be completed) 90422-7 DRUG PRESCRIBED, TOPICAL THERAPY- REASON, OTHER Description of reason for topical therapy, required when response to Drug Prescribed, Topical Therapy - Reason equals "OTH" Other. 90430-7 IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS Diagnosis information related to the prescribed drug. 90431-7 IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS This is the related diagnosis of the patient for which the drug is a prescribed therapy. 1,1 CE 1,1 IC9 IC10 CE 0,n HL79070 TX 0,1 Note: Prior to U.S. adoption of ICD-10-CM, use ICD-9-CM in the U.S. domain. After adoption as the standard for defining diagnoses in the US, use only ICD-10-CM for requests in the US. 90432-7 IMIDAZOLE-RELATED ANTIFUNGALS, DIAGNOSIS CONFIRMED BY This conveys the diagnostic procedures used to establish the diagnosis. See section 5 for the list of valid codes. 90433-7 IMIDAZOLE-RELATED ANTIFUNGALS, DIAGNOSIS CONFIRMED BY - OTHER Name/description of other test used to confirm the diagnosis. Required when the answer to Patient History, Diagnosis Confirmed equals "OTH" Other. Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page 39 November 2005 Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer 90440-7 Value CDAR1AIS0010R010 Data Type FUNGAL INFECTION INFORMATION Information about the fungal infection. 90441-7 FUNGAL INFECTION INFORMATION, LOCATION This defines the general site of the fungal infection. Card Response Code / Numeric Units 1,1 CE 1,n 90442-7 FUNGAL INFECTION INFORMATION, LOCATION – OTHER Description of the location of the fungal infection. Required when Fungal Infection Information, Location equals "OTH" Other TX 0,1 90443-7 FUNGAL INFECTION INFORMATION, NUMBER OF NAILS Enumerates the number of affected finger and or toe nails. NM 0,1 HL79071 FN Finger Nail TN Toe Nail OTH Other (If used, then Fungal Infection Information, Location – Other must be completed) 90450-7 0,n IMMUNE COMPROMISE INFORMATION Information regarding the source and verification of the patient’s immune compromise. 90451-7 IMMUNE COMPROMISE INFORMATION, CAUSE This conveys the cause of the patient's immune compromise. iso+ CE 1,n HL79072 CE 0,n HL79073 DIS Disease TRP Transplant MED Medical Intervention NA Not Applicable 90452-7 IMMUNE COMPROMISE INFORMATION, VERIFIED BY This identifies the laboratory procedure used to verify immune compromise. CD4 CD4 Count ANC ANC Count WBC White Blood Cell Count 90460-7 90461-7 CO-MORBID CONDITON INFORMATION Information regarding the presence of other conditions as factor in the existence and treatment of the fungal infection. 0,1 CO-MORBID CONDITON INFORMATION, LIVER DYSFUNCTION INDICATOR This provides information regarding the presence of liver dysfunction as factor in the continuation and treatment of the fungal infection.. 0,1 HL70136 1,1 HL79074 N No Y Yes 90462-7 CO-MORBID CONDITON INFORMATION, LIVER DYSFUNCTION - CONFIRMED BY This defines the tests used to verify the liver dysfunction. CE See section 5 for the list of valid codes. Page 40 November 2005 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value CDAR1AIS0010R010 Data Type Card 90463-7 CO-MORBID CONDITON INFORMATION, LIVER TX DYSFUNCTION COMFIRMED BY – OTHER Description of test used to confirm Liver Dysfunction. Required when the response to Co-morbid Condition Information, Liver Dysfunction - Confirmed By equals "OTH" Other. 0,1 90464-7 1,1 COMORBID CONDITON INFORMATION, MEDICARE ESRD CERTIFICATION - INDICATOR This provides information regarding the presence of End Stage Renal Disease as factor in the continuation and treatment of the fungal infection, based on Medicare ESRD certification. CE Response Code / Numeric Units H70136 Y Yes N No 90070-x 0,1 MEDICARE ESRD CERTIFICATION DATE Date patient was certified by Medicare as having End Stage Renal Disease 90070-x . 90470-7 DT LEVEL OF FUNCTIONAL IMPAIRMENT This conveys functional limitations resulting from or exacerbating the fungal infection. 90470-7 1,1 0,1 CE 1,n HL79075 See section 5 for the list of valid codes. 90480-7 INPATIENT TREATMENT INFORMATION Required if the patient is being discharged from an inpatient hospital stay during which anti-fungal treatment was administered. 90481-7 INPATIENT TREATMENT INFORMATION, IV ANTIFUNGAL THERAPY INDICATOR Indicator to define whether IV Anti-fungal therapy was provided during the admission. 0,1 CE 1,1 TX 0,1 HL70136 N No Y Yes 90482-7 INPATIENT TREATMENT INFORMATION, IV ANTIFUNGAL THERAPY – AGENT(S) Name of the IV Therapy Agents given during the hospital stay. 90080-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS Information about other drugs previously prescribed for treatment of this condition with less than optimal outcomes. 90081-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS DRUG NAME This is the descriptive name of the drug previously used to treat the diagnosis. 90082-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS DRUG CODE The code assigned to the drug previously used to treat the diagnosis as defined by: Representative NDC, RxNorm SCD or RxNorm SBD Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard 0,n TX 1,1 CE 1,1 NDC RxNorm SCD RxNorm SBD Page 41 November 2005 Additional Information Specification 0010: PharmPA Attachment LOINC code Component Answer Value Data Type Card 90083-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS DURATION OF THERAPY Duration of previous therapy in days. NM 1,1 iso+ 90084-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS REASON(S) PRIOR THERAPY DISCONTINUED This is the reason that the prior drug therapy was discontinued. CE 1,1 HL79040 90085-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS, REASON PRIOR THERAPY DISCONTINUED – OTHER Description of the other reason for discontinued therapy. If Drug History, Prior Therapy for Diagnosis - Reason Prior Therapy Discontinued equals "OTH" Other, then this is required. TX 0,1 90086-x DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS INCOMPATIBLE DRUG NAME The descriptive name of the drug(s) incompatible with the prior therapy. If Drug History, Prior Therapy for Diagnosis - Reason Prior Therapy Discontinued equals "NTCMP" Not Compatible, then this is required. TX 0,n CE 0,1 NTEFF SDEFT NTCMP OTH 90490-7 2005 Not or No Longer Effective Side Effects/Tolerance Not Compatible Other IMIDAZOLE-RELATED ANTIFUNGALS, PRIOR THERAPY TYPE Type of drug therapy previously used for treatment of the fungal infection. ORL TOP INJ IV Page 42 November Response Code / Numeric Units IMIDAZOLE-RELATED ANTIFUNGALS, PRIOR THERAPY TYPE The route of the previously used medication for treatment of the fungal infection. 90490-7 90090-x CDAR1AIS0010R010 HL79076 Oral Topical Injectible Intravenous CONCURRENT THERAPY Drugs the patient is currently on, for this or other diagnoses, which may impact the requested drug. 0,n 90091-x CONCURRENT THERAPY, DRUG NAME This is the descriptive name of the drugs) the patient is currently on, for this or other diagnoses, which might impact the requested drug. TX 0,1 90092-x CONCURRENT THERAPY, DRUG CODE The code assigned to the concurrent drug as defined by: Representative NDC, RxNorm SCD, or RxNorm SBD CE 1,1 NDC RxNorm SCD RxNorm SBD Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 4 Coding Examples 4.1 Scenario Sara J. Smith is a 50 year old female receiving care for hepatic dysfunction and a persistent fungal infection of her right foot. She returned to her physician, Robert J Podell, MD, a Hepatologist (Taxonomy 207RI0008X) for a follow-up evaluation on 12/28/2005. Ms. Smith’s medical record number is 184569 The findings at this time revealed that the medication, Tinactin Cream, had not proved effective in controlling the Tenea Pedis infection. Because of her diminished liver function Ms. Smith is unable to take a systemic anti-fungal medication, so Dr. Podell decides to order Oxistat Cream, 1%, 60 gram tube (NDC-0173-0423-04) as a replacement therapy. Ms. Smith has medical and drug coverage through Aetna Insurance, Plan ID 10567432.Her Aetna patient ID is 352584768003G. The Plan’s drug benefit is administered by ReadiRx PBM. On checking the Plan formulary, Dr. Podell finds that Oxistat Cream is a covered benefit requiring prior authorization. Using the Plan’s Antifungal PA Attachment and criteria for coverage of coverage of Oxistat Cream, he reviews Ms. Smith’s medical record to assure that she meets the criteria and to collect the information needed for the request. Dr. Podell’s Aetna provider ID is 4376557IM. The following information was collected from the medical record. The diagnosis requiring the use of the ordered drug is 110.4 - Tinea Pedis. This diagnosis was confirmed by KOH Preparation performed on 9/15/2004. The use of a topical drug is required because of Liver Dysfucntion as confirmed by a 7/15/2004 Hepatic Function Panel. The fungal infection is located between the toes of her right foot and at this point is not causing or impacted by any function limitations. The previous treatment which proved ineffective, was with Tinactin Cream, NDC-0085-0715-07. The request associated with this CDA document is identified by the value XA728302 as it’s attachment control number. This is used for linking purposes within the 278 and 275. Figure 4.1 Drug Prior Authorization Additional Data PRESCRIBER NAME PRESCRIBER IDENTIFIER PRESCRIBER TAXONOMY Podell MD, Robert J 4376557IM 207RI0008X PRESCRIBER CONTACT PHONE # PRESCRIBER CONTACT FAX # 765-228-1234 765-228-3123 DRUG PRESCRIBED, NAME (TEXT) DRUG PRESCRIBED, DRUG CODE DRUG PRESCRIBED, THERAPY TYPE Oxistat, Cream, 1%, 60-g tube 0173-0423-04 Replacement (RPLRQ) DRUG PRESCRIBED, REASON FOR TOPICAL THERAPY Hepatic Dysfunction (HDS) RELATED DIAGNOSIS (TEXT) RELATED DIAGNOSIS (CODE) RELATED DIAGNOSIS CONFIRMED BY Tinea Pedia 110.4 KOH Preparation (KOH) INFECTION LOCATION Between toes, right foot (OTH) LIVER DYSFUNCTION INDICATOR LIVER DYSFUNTION CONFIRMED BY Yes (Y) Hepatic Function Panel (HFP) Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page 43 November 2005 Additional Information Specification 0010: PharmPA Attachment MEDICARE ESRD CERTIFICATION INDICATOR Yes (Y) PRIOR THERAPY, DRUG NAME PRIOR THERAPY, DRUG CODE PRIOR THERAPY, DURATION PRIOR THERAPY, RREASON PRIOR THERAPY DISCONTINUED PRIOR THERAPY, TYPE Tinactin, Cream 0085-0715-07 90 days Not or no longer effective (NTEFF) CDAR1AIS0010R010 Topical (TOP) 4.1.1 Drug Prior Authorization Attachment, Human-Decision Variant (XML body) The right column of the example below contains the single HL7 document in the human-decision variant that conveys this report in its entirety. The left column provides help in relating the example to the scenario and to the Value Table. Example 4.1.1 Drug Prior Authorization Attachment, Human-Decision Variant (XML body) Header Provider Identification Patient Identification Attachment Control Number Page 44 November 2005 <levelone xmlns="urn:hl7-org:v3/cda" xmlns:v3dt="urn:hl7-org:v3/v3dt" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7org:v3/cda levelone_1.0.attachments.xsd"> <clinical_document_header> <id EX="a123" RT="2.16.840.1.113883.3.933"/> <document_type_cd V="99999-7" DN="Imidazole–Related Antifungals Attachment"/> <origination_dttm V="2006-01-05"/> <provider> <provider.type_cd V="PRF"/> <person> <id EX="4376557IM" RT="2.16.840.1.113883.19.10.1"/> <person_name> <nm> <v3dt:GIV V="Robert"/> <v3dt:MID V="J"/> <v3dt:FAM V="Podell"/> <v3dt:SFX V="MD"/> </nm> <person_name.type_cd V="L" S="2.16.840.1.113883.12.200"/> </person_name> </person> </provider> <patient> <patient.type_cd V="PATSBJ"/> <person> <id EX="352584768003G" RT="2.16.840.1.113883.19.10.2"/> <person_name> <nm> <v3dt:GIV V="Sara"/> <v3dt:MID V="J"/> <v3dt:FAM V="Smith"/> </nm> <person_name.type_cd V="L" S="2.16.840.1.113883.12.200"/> </person_name> </person> <is_known_by> <id EX="184569" RT="2.16.840.1.1138863.19.10.3"/> <is_known_to> <id EX="352584768003G" RT="2.16.840.1.113883.19.10.2"/> </is_known_to> </is_known_by> </patient> <local_header descriptor="Att_ACN"> <local_attr name="attachment_control_number" value="XA728302"/> </local_header> </clinical_document_header> Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment Prescriber Information (Name, Identifier and Taxonomy) Prescriber Contact Information (phone and fax numbers) Drug Prescribed Information (Name of Drug, Drug Code and Therapy Type) Drug Prescribed, Reason for Topical Therapy Related Diagnosis Information (Diagnosis Description and Code and how the diagnosis was confirmed) Fungal Infection Location CDAR1AIS0010R010 <body> <section> <caption>PRESCRIBER INFORMATION</caption> <paragraph> <caption>PRESCRIBER INFORMATION, NAME</caption> <content>Robert J. Podell, MD</content> </paragraph> <paragraph> <caption>PRESCRIBER INFORMATION, IDENTIFIER</caption> <content>4376557IM</content> </paragraph> <paragraph> <caption>PRESCRIBER INFORMATION, SPECIALTY TAXONOMY</caption> <content>Hepatologist (207RI0008X)</content> </paragraph> </section> <section> <caption>PRESCRIBER CONTACT INFORMATION</caption> <paragraph> <caption>PRESCRIBER CONTACT INFORMATION, PHONE NUMBER</caption> <content>(765) 228-1234</content> </paragraph> <paragraph> <caption>PRESCRIBER CONTACT INFORMATION, FAX NUMBER</caption> <content>(765) 228-3123</content> </paragraph> </section> <section> <caption>DRUG PRESCRIBED</caption> <paragraph> <caption>DRUG PRESCRIBED, NAME</caption> <content>Oxistat Cream, 1%, 60g tube</content> </paragraph> <paragraph> <caption>DRUG PRESCRIBED, DRUG CODE</caption> <content>0173-0423-04 (NDC)</content> </paragraph> <paragraph> <caption>DRUG PRESCRIBED, THERAPY TYPE</caption> <content>Replacement (RPLRQ)</content> </paragraph> </section> <section> <caption>DRUG PRESCRIBED, REASON FOR TOPICAL THERAPY</caption> <paragraph> <content>Hepatic Dysfunction (HDS)</content> </paragraph> </section> <section> <caption>IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS</caption> <paragraph> <caption>IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS</caption> <content>Tinea Pedia (ICD-9-CM 110.4)</content> </paragraph> <paragraph> <caption>IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS CONFIRMED BY</caption> <content>KOH Preparation (KOH)</content> </paragraph> </section> <section> <caption>FUNGAL INFECTION LOCATION</caption> <paragraph> <content>Between Toes, right foot (OTH)</content> </paragraph> Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page 45 November 2005 Additional Information Specification 0010: PharmPA Attachment Liver Dysfunction Information (Indicator and how it was confirmed) </section> <section> <caption>CO-MORBID CONDITION INFORMATION</caption> <paragraph> <caption>CO-MORBID CONDITION INFORMATION, LIVER DYSFUNCTION INDICATOR</caption> <content>yes (Y)</content> </paragraph> <paragraph> <caption>CO-MORBID CONDITION INFORMATION, LIVER DYSFUNCTION CONFIRMED BY</caption> <content>Hepatic Function Panel (HFP)</content> </paragraph> </section> <section> <caption>MEDICARE ESRD CERTIFICATION INDICATOR</caption> <paragraph> <content>Yes (Y)</content> </paragraph> </section> <section> <caption>DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS</caption> Medicare ESRD Certification Indicator Drug History, Prior Therapy for Diagnosis (Prior Therapy Drug Name, Code, Duration, and Reason for Discontinuance) Prior Therapy Type CDAR1AIS0010R010 <paragraph> <caption>DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG NAME</caption> <content>Tinactin Cream</content> </paragraph> <paragraph> <caption>DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG CODE</caption> <content>0085-0715-07 (NDC)</content> </paragraph> <paragraph> <caption>DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS DURATION OF THERAPY</caption> <content>90 days</content> </paragraph> <paragraph> <caption>DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR THERAPY DISCONTINUED</caption> <content>Not or no longer effective (NTEFF)</content> </paragraph> </section> <section> <caption>IMIDAZOLE-RELATED ANTIFUNGALS, PRIOR THERAPY TYPE</caption> <paragraph> <content>Topical (TOP)</content> </paragraph> </section> </body> </levelone> Figure 1 shows the human-decision variant (XML body) as rendered by a popular browser. Figure 1. Rendered Human-Decision Variant (XML body) Drug Prior Authorization Attachment Provider: Robert J Podell, Page 46 November 2005 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 MD Patient: Sara J Smith Provider's Pt ID: 352584768003G Attachment Control Number: XA728302 PRESCRIBER INFORMATION PRESCRIBER INFORMATION, NAME. Robert J. Podell, MD PRESCRIBER INFORMATION, IDENTIFIER. 4376557IM PRESCRIBER INFORMATION, SPECIALTY TAXONOMY. Hepatologist (207RI0008X) PRESCRIBER CONTACT INFORMATION PRESCRIBER CONTACT INFORMATION, PHONE NUMBER. (765) 228-1234 PRESCRIBER CONTACT INFORMATION, FAX NUMBER. (765) 228-3123 DRUG PRESCRIBED DRUG PRESCRIBED, NAME. Oxistat Cream, 1%, 60g tube DRUG PRESCRIBED, DRUG CODE. 0173-0423-04 (NDC) DRUG PRESCRIBED, THERAPY TYPE. Replacement (RPLRQ) DRUG PRESCRIBED, REASON FOR TOPICAL THERAPY Hepatic Dysfunction (HDS) IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS. Tinea Pedia (ICD-9-CM 110.4) IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS - CONFIRMED BY. KOH Preparation (KOH) FUNGAL INFECTION LOCATION Between Toes, right foot (OTH) CO-MORBID CONDITION INFORMATION CO-MORBID CONDITION INFORMATION, LIVER DYSFUNCTION INDICATOR. yes (Y) CO-MORBID CONDITION INFORMATION, LIVER DYSFUNCTION CONFIRMED BY. Hepatic Function Panel (HFP) Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page 47 November 2005 Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 MEDICARE ESRD CERTIFICATION INDICATOR Yes (Y) DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG NAME. Tinactin Cream DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG CODE. 0085-071507 (NDC) DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DURATION OF THERAPY. 90 days DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR THERAPY DISCONTINUED. Not or no longer effective (NTEFF) IMIDAZOLE-RELATION ANTIFUNGALS, PRIOR THERAPY TYPE Topical (TOP) Page 48 November 2005 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 4.1.2 Drug Prior Authorization Attachment, Human-Decision Variant (non-XML body) The right column of the example below contains the single HL7 Additional Information CDA document in the human-decision variant that conveys this report in its entirety. The left column provides help in relating the example to the scenario and to the Value Table. Example 4.1.2 Drug Prior Authorization Attachment, Human-Decision Variant (non-XML body) Header Provider Identification Patient Identification Attachment Control Number MIME Reference for Antifungal Report Base64 Encoded Antifungal Report (this is an example of a portion of the MIME packaging) <levelone xmlns="urn:hl7-org:v3/cda" xmlns:v3dt="urn:hl7-org:v3/v3dt" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7org:v3/cda levelone_1.0.attachments.xsd"> <clinical_document_header> <id EX="a123" RT="2.16.840.1.113883.3.933"/> <document_type_cd V="99999-7" DN="Imidazole–Related Antifungals Attachment"/> <origination_dttm V="2006-01-05"/> <provider> <provider.type_cd V="PRF"/> <person> <id EX="4376557IM" RT="2.16.840.1.113883.19.10.1"/> <person_name> <nm> <v3dt:GIV V="Robert"/> <v3dt:MID V="J"/> <v3dt:FAM V="Podell"/> <v3dt:SFX V="MD"/> </nm> <person_name.type_cd V="L" S="2.16.840.1.113883.12.200"/> </person_name> </person> </provider> <patient> <patient.type_cd V="PATSBJ"/> <person> <id EX="352584768003G" RT="2.16.840.1.113883.19.10.2"/> <person_name> <nm> <v3dt:GIV V="Sara"/> <v3dt:MID V="J"/> <v3dt:FAM V="Smith"/> </nm> <person_name.type_cd V="L" S="2.16.840.1.113883.12.200"/> </person_name> </person> <is_known_by> <id EX="184569" RT="2.16.840.1.1138863.19.10.3"/> <is_known_to> <id EX="352584768003G" RT="2.16.840.1.113883.19.10.2"/> </is_known_to> </is_known_by> </patient> <local_header descriptor="Att_ACN"> <local_attr name="attachment_control_number" value="XA728302"/> </local_header> </clinical_document_header> <body> <non_xml MT=”image/tif”> <v3dt:REF V=”Antifungal report.tif”/> </non_xml> </body> </levelone> --192.168.0.132.1.111780.1044168570.525.24086 Content-Type: image/tif Content-Transfer-Encoding: base64 Content-Disposition: attachment; filename=Antifungal report.tif Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page 49 November 2005 Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 R0lGODlhAAJ9AfAAAP///wAAACwAAAAAAAJ9AUAC/wQShrqcb06SrNITm57bTvqB0dWRUM al nmqubkuib0lDyHIrYz2zPPzDZUbEou5oJNpiuVPDIXngptIqkIP5aFesq2eIDGLDPhksiU47 nsVbiOqeotjtnPp+f8a17FAFTrez95Yid6FkZ4e24cdocSiIJzlJWWl5WekWNVjot9kUZ8YZ tfmpF/q5VmWFmRl4xBkrO6topNmKm6u7y9vr+/u7J+k5WVure5wJlhTafKuICrwGBkhrfS2c (Editor’s note: 149 lines have been suppressed for readability.) SmW6Sr0UTL2M5ut4yN5k7soG7vici6fc6QHbTh+khPZMrOHMrvfaCpkaUNm0rvTUBcSEJ6cQ o+wwjU0oJrAQ74fqZ+jewudY7N5KEOPm6rVEcMoOqbVaD/1ubkQyba+eiRj0TwZ/LteWkAmt Yf8QcMwmRGuCkAajRZjSYm+ojQq30FL6zu24EAzrJ8XCkAzl4fTKEA3TUA3XkA3b0A3fEA7j 0C0IAAUAOw== --192.168.0.132.1.111780.1044168570.525.24086 Figure 2 shows the human-decision variant (non-XML body) as rendered by a popular browser. Figure 2. Rendered Human-Decision Variant (non-XML body) Imidazol-Related Antifungals Attachment Provider: Robert J Podell, MD Patient: Sara J Smith Provider's Pt ID: 352584768003G Attachment Control Number: XA728302 Click here to view report. Page 50 November 2005 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard CDAR1AIS0010R010 Page 51 November 2005 Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 4.1.3 Coded Drug Prior Authorization Attachment, Computer-Decision Variant The right column of the example below contains the single HL7 Additional Information CDA document in the computer-decision variant that conveys this report in its entirety. The left column provides help in relating the example to the scenario and to the Value Table. Example 4.1.2 Drug Prior Authorization Attachment, Computer-Decision Variant Header Provider Identification Patient Identification Attachment Control Number Prescriber Information (Name, Identifier and Taxonomy) Page 52 November 2005 <levelone xmlns="urn:hl7-org:v3/cda" xmlns:v3dt="urn:hl7-org:v3/v3dt" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7org:v3/cda levelone_1.0.attachments.xsd"> <clinical_document_header> <id EX="a123" RT="2.16.840.1.113883.3.933"/> <document_type_cd V="99999-7" DN="Imidazole–Related Antifungals Attachment"/> <origination_dttm V="2006-01-05"/> <provider> <provider.type_cd V="PRF"/> <person> <id EX="4376557IM" RT="2.16.840.1.113883.19.10.1"/> <person_name> <nm> <v3dt:GIV V="Robert"/> <v3dt:MID V="J"/> <v3dt:FAM V="Podell"/> <v3dt:SFX V="MD"/> </nm> <person_name.type_cd V="L" S="2.16.840.1.113883.12.200"/> </person_name> </person> </provider> <patient> <patient.type_cd V="PATSBJ"/> <person> <id EX="352584768003G" RT="2.16.840.1.113883.19.10.2"/> <person_name> <nm> <v3dt:GIV V="Sara"/> <v3dt:MID V="J"/> <v3dt:FAM V="Smith"/> </nm> <person_name.type_cd V="L" S="2.16.840.1.113883.12.200"/> </person_name> </person> <is_known_by> <id EX="184569" RT="2.16.840.1.1138863.19.10.3"/> <is_known_to> <id EX="352584768003G" RT="2.16.840.1.113883.19.10.2"/> </is_known_to> </is_known_by> </patient> <local_header descriptor="Att_ACN"> <local_attr name="attachment_control_number" value="XA728302"/> </local_header> </clinical_document_header> <body> <section> <caption>PRESCRIBER INFORMATION <caption_cd V="90010=x" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <paragraph> <caption>PRESCRIBER INFORMATION, NAME <caption_cd V="90011-x" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <content>Robert J. Podell, MD <local_markup descriptor="dt_PN"> <local_markup descriptor="dt_PN_GIV" ignore="all">ROBERT</local_markup> <local_markup descriptor="dt_PN_MID" ignore="all">J</local_markup> Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment Prescriber Contact Information (phone and fax numbers) Drug Prescribed Information (Name of Drug, Drug Code and Therapy Type) CDAR1AIS0010R010 <local_markup descriptor="dt_PN_FAM" ignore="all">PODELL</local_markup> <local_markup descriptor="dt_PN_SFX" ignore="all">MD</local_markup> </local_markup> </content> </paragraph> <paragraph> <caption>PRESCRIBER INFORMATION, IDENTIFIER <caption_cd V="90012-x" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <content>4376557IM <local_markup descriptor="dt_CX"> <local_attr name="dt_CX_EX" value="4376557IM"/> <local_attr name="dt_CX_RT" value="2.16.840.1.113883.19.10.1"/> </local_markup> </content> </paragraph> <paragraph> <caption>PRESCRIBER INFORMATION, SPECIALTY TAXONOMY <caption_cd V="90013-x" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <content>207RI0008X Hepatologist <coded_entry> <coded_entry.value V="207RI0008X" S="2.16.840.1.113883.6.101" SN="USProvTxnmy"/> </coded_entry> </content> </paragraph> </section> <section> <caption>PRESCRIBER CONTACT INFORMATION <caption_cd V="90020-x" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <paragraph> <caption>PRESCRIBER CONTACT INFORMATION, PHONE NUMBER <caption_cd V="90021-x" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <content>(765)228-1234</content> </paragraph> <paragraph> <caption>PRESCRIBER CONTACT INFORMATION, FAX NUMBER <caption_cd V="90022-x" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <content>(765)228-3123</content> </paragraph> </section> <section> <caption>DRUG PRESCRIBED <caption_cd V="90030-x" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <paragraph> <caption>DRUG PRESCRIBED, NAME <caption_cd V="90031-x s=2.16.840.1.113883.6.1" SN="loinc"/> </caption> <content>Oxistat Cream, 1%, 60g tube</content> </paragraph> <paragraph> <caption>DRUG PRESCRIBED, DRUG CODE <caption_cd V="90032-x" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <content>0173-0423-04 Oxistat Cream, 1%, 60g tube <coded_entry> <coded_entry.value V="0173-0423-04" S="2.16.840.1.113883.5.141" SN="NDC"/> </coded_entry> </content> </paragraph> <paragraph> <caption>DRUG PRESCRIBED, THERAPY TYPE <caption_cd V="90033-x" S="2.16.840.1.113883.6.1" SN="LOINC"/> Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page 53 November 2005 Additional Information Specification 0010: PharmPA Attachment Drug Prescribed, Reason for Topical Therapy Related Diagnosis Information (Diagnosis Description and Code and how the diagnosis was confirmed) Fungal Infection Location Co-Morbid Condition Information (Liver Dysfunction) (Indicator and how it was confirmed) Page 54 November 2005 CDAR1AIS0010R010 </caption> <content>Replacement (RPLRQ) <coded_entry> <coded_entry.value V="RPLRQ" S="2.16.840.1.113883.12.9038" SN="HL79038"/> </coded_entry> </content> </paragraph> </section> <section> <caption>DRUG PRESCRIBED, REASON FOR TOPICAL THERAPY <caption_cd V="90420-7" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <paragraph> <content>Hepatic Dynsfunction (HDS) <coded_entry> <coded_entry.value V="HDS" S="2.16.840.1.113883.12.9069" SN="HL79069"/> </coded_entry> </content> </paragraph> </section> <section> <caption>IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS <caption_cd V="90430-7" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <paragraph> <caption>IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS <caption_cd V="90431-7" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <content>Tinea Pedia 110.4 (ICD-9-CM) <coded_entry> <coded_entry.value V="110.4" S="2.16.840.1.113883.12.6.2" SN="ICD-9-CM"/> </coded_entry> </content> </paragraph> <paragraph> <caption>IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS CONFIRMED BY <caption_cd V="90432-7" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <content>KOH Preparation (KOH) <coded_entry> <coded_entry.value V="KOH" S="2.16.840.1.113883.12.9070" SN="HL79070"/> </coded_entry> </content> </paragraph> </section> <section> <caption>FUNGAL INFECTION LOCATION - OTHER <caption_cd V="90442-7" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <paragraph> <content>Between toes, right foot</content> </paragraph> </section> <section> <caption>CO-MORBID INFORMATION <caption_cd V="90460-7" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <paragraph> <caption>CO-MORBID INFORMATION, LIVER DYSFUNCTION INDICATOR <caption_cd V="90461-7" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <content>Yes (Y) <coded_entry> Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 <coded_entry.value V="Y" S="2.16.840.1.113883.12.136" SN="HL70136"/> Medicare ESRD Certification Indicator Drug History, Prior Therapy for Diagnosis (Prior Therapy Drug Name, Code, Duration, and Reason for Discontinuance) </coded_entry> </content> </paragraph> <paragraph> <caption>CO-MORBID INFORMATION, LIVER DYSFUNCTION CONFIRMED BY <caption_cd V="90462-7" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <content>Hepatic Function Panel (HFP) <coded_entry> <coded_entry.value V="HFP" S="2.16.840.1.113883.12.9074" SN="HL79074"/> </coded_entry> </content> </paragraph> </section> <section> <caption>MEDICARE ESRD CERTIFICATION INDICATOR <caption_cd V="90070-x" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <paragraph> <content>Yes (Y) <coded_entry> <coded_entry.value V="Y " S="2.16.840.1.113883.12.136" SN="HL70136"/> </coded_entry> </content> </paragraph> </section> <section> <caption>DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS <caption_cd V="90080-x" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <paragraph> <caption>DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG NAME <caption_cd V="90081-x" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <content>Tinactin Cream</content> </paragraph> <paragraph> <caption>DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG CODE <caption_cd V="90082-x" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <content>0085-0715-07 (NDC) <coded_entry> <coded_entry.value V="0085-0715-07 " S="2.16.840.1.113883.5.141" SN="NDC"/> </coded_entry> </content> </paragraph> <paragraph> <caption>DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS DURATION OF THERAPY <caption_cd V="90083-x" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <content>90 days <local_markup descriptor="dt_nm" ignore="all">90 <coded_entry> <coded_entry.value V="days" S="2.16.840.1.113883.6.2"/> </coded_entry> </local_markup> </content> </paragraph> <paragraph> <caption>DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR THERAPY DISCONTINUED <caption_cd V="90084-x" S="2.16.840.1.113883.6.1" SN="LOINC"/> Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page 55 November 2005 Additional Information Specification 0010: PharmPA Attachment Prior Therapy Type CDAR1AIS0010R010 </caption> <content>Not or no longer effective (NTEFF) <coded_entry> <coded_entry.value V="NTEFF" S="2.16.840.1.113883.12.9040" SN="HL79040"/> </coded_entry> </content> </paragraph> </section> <section> <caption>DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR THERAPY DISCONTINUED <caption_cd V="90084-x" S="2.16.840.1.113883.6.1" SN="LOINC"/> </caption> <paragraph> <content>Topical (TOP) <coded_entry> <coded_entry.value V="TOP" S="2.16.840.1.113883.12.9076" SN="HL79076"/> </coded_entry> </content> </paragraph> </section> </body> </levelone> Figure 3 shows a portion of the computer-decision variant as rendered by a popular browser. It includes the medications rendered as a table. Figure 3. Rendered Human-Decision Variant (non-XML body) Imidazol-Related Antifungals Attachment Provider: Robert J Podell, MD Patient: Sara J Smith Attachment Control Number: Provider's Pt ID: 352584768003G XA728302 PRESCRIBER INFORMATION PRESCRIBER INFORMATION, NAME. Robert J. Podell, MD PRESCRIBER INFORMATION, IDENTIFIER. 4376557IM PRESCRIBER INFORMATION, SPECIALTY TAXONOMY. 207RI0008X Hepatologist PRESCRIBER CONTACT INFORMATION PRESCRIBER CONTACT INFORMATION, PHONE NUMBER. (765)228-1234 PRESCRIBER CONTACT INFORMATION, FAX NUMBER. (765)228-3123 DRUG PRESCRIBED DRUG PRESCRIBED, NAME. Oxistat Cream, 1%, 60g tube Page 56 November 2005 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 DRUG PRESCRIBED, DRUG CODE. 0173-0423-04 Oxistat Cream, 1%, 60g tube DRUG PRESCRIBED, THERAPY TYPE. Replacement (RPLRQ) DRUG PRESCRIBED, REASON FOR TOPICAL THERAPY Hepatic Dynsfunction (HDS) IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS. Tinea Pedia 110.4 (ICD-9-CM) IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS - CONFIRMED BY. KOH Preparation (KOH) FUNGAL INFECTION LOCATION - OTHER Between toes, right foot CO-MORBID INFORMATION CO-MORBID INFORMATION, LIVER DYSFUNCTION INDICATOR. Yes (Y) CO-MORBID INFORMATION, LIVER DYSFUNCTION CONFIRMED BY. Hepatic Function Panel (HFP) MEDICARE ESRD CERTIFICATION INDICATOR Yes (Y) DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG NAME. Tinactin Cream DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG CODE. 0085-071507 (NDC) DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DURATION OF THERAPY. 90 days DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR THERAPY DISCONTINUED. Not or no longer effective (NTEFF) DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR THERAPY DISCONTINUED Topical (TOP) Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page 57 November 2005 Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 5 Response Code Sets This section describes response codes that may be used in the computer-decision variant when the value table indicates a coded with exception (CE) data type or to represent units when the attachment component is of the numeric (NM) data type. The entry in the value table that refers to these code sets is used in the subsection titles. The values for some code sets appear directly in this document. In other cases, the section cites another document as the source. 5.1 HL70136: Yes-No Indicator The OID for this table is 2.16.840.1.113883.12.136. Table 5.1 Yes-No Indicator Code N Y 5.2 Description No Yes Additional Comments HL79038: Drug Prescribed, Therapy Type The OID for this table is 2.16.840.1.113883.12.9038. Table 5.2 Drug Prescribed, Therapy Type Code INTRQ CNTRQ RPLRQ ADDRQ 5.3 Description Initial Therapy Continued Therapy Replacement Therapy Add-on Therapy Additional Comments HL79039: UTC, Diagnosis Confirmed By The OID for this table is 2.16.840.1.113883.12.9039. Table 5.3 UTC, Diagnosis Confirmed By Code LABT RADT OTDX CLNE Page 58 November 2005 Description Laboratory Examination Radiological Examination Other Diagnostic Examination Clinical Evaluation Additional Comments Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment 5.4 CDAR1AIS0010R010 HL79040: Reason Prior Therapy Discontinued The OID for this table is 2.16.840.1.113883.12.9040. Table 5.4 Reason Prior Therapy Discontinued Code NTEFF SDEFT NTCMP Description Not or No Longer Effective Side Effects/Tolerance Not Compatible OTH Other 5.5 Additional Comments Not compatible with other required drugs. If used, then Reason Prior Therapy Discontinued – Other must be completed HL79041: NSAIDS/PPI Related Concurrent Therapy, Type The OID for this table is 2.16.840.1.113883.12.9041. Table 5.5 NSAIDS – COX 2 Inhibitors, Concurrent Therapy - Type Code CRTC ANCG ANPL PPI H2RA NSAD BPHN ANNP FAP ASAL ASAG OTH 5.6 Description Corticosteroid Anti-coagulant Anti-platelet Proton Pump Inhibitor H2 Receptor Antagonist NSAIDS Biphosphonate Anti-neoplastic For Familial Adenomatous Polposis ASA<325mg/day ASA>325mg/day Other Additional Comments If used, then Drug History, Other Drug Type must be completed. HL79042: NSAID Use, Duration The OID for this table is 2.16.840.1.113883.12.9042. Table 5.6 NSAID Use, Duration Code G21 L21 5.7 Description NSAID Use greater than 21 days NSAID Use less than 21 days Additional Comments HL79043: Yes-No-Unknown Indicator The OID for this table is 2.16.840.1.113883.12.9043. Table 5.7 HL7 NSAID Use, Duration Code Y N U Description Yes No Unknown Additional Comments Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page 59 November 2005 Additional Information Specification 0010: PharmPA Attachment 5.8 CDAR1AIS0010R010 HL79044: Radiology Diagnosis Confirmation, Study Type The OID for this table is 2.16.840.1.113883.12.9044. Table 5.8 Radiology Diagnosis Confirmation, Study Type Code BAE BDY MRI ESX 5.9 Description Bone Age Bone Density Magnetic Resonance Imaging (MRI) X-Ray to Determine Epiphyseal Status Additional Comments HL79045: Laboratory Diagnosis Confirmation, Study/Test The OID for this table is 2.16.840.1.113883.12.9045. Table 5.9 Laboratory Diagnosis Confirmation, Study/Test Code IGB3 IGF1 ITT ACTH TSH LIP GHA GTP FTST GT OTH Description IGFBP3 IGF1 Insulin Tolerance ACTH TSH Lipid Level Combined GHRH and Arginine Gonadotropin Free Testosterone Genetic Testing Other Additional Comments If ITT contraindicated. If used, then Laboratory Diagnosis Confirmation Information, Other Study/Test Name must be used. 5.10 HL79046: GH, Patient History – Documented Onset The OID for this table is 2.16.840.1.113883.12.9046. Table 5.10 GH, Patient History – Documented Onset Code AO CO UO Description Adult Onset Childhood Onset Unknown Onset Additional Comments 5.11 HL79047: GH, Patient History Information – Hypothalmic Pituitary Disease Induced By The OID for this table is 2.16.840.1.113883.12.9047. Table 5.11 GH, Patient History Information – Hypothalmic Pituitary Disease Induced By Page 60 November 2005 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment Code PTT IRR SUG HMN TRA Description Pituitary Tumor Irradiation Surgery Hormone Dysfunction or Therapy Trauma CDAR1AIS0010R010 Additional Comments 5.12 HL79048: Treatment Status The OID for this table is 2.16.840.1.113883.12.9048. Table 5.12 Treatment Status Code AT IT CP PT NT PL Description In Progress/Active Treatment Initial Course of Treatment Completed Previously Treated New Course of Treatment Planned Additional Comments 5.13 HL79049: GHD Childhood Information, Puberty Status The OID for this table is 2.16.840.1.113883.12.9049. Table 5.13 GHD Childhood Information, Puberty Status Code BP AP PS Description Pre-pubertal Post Pubertal Pubertal Additional Comments 5.14 HL79050: GH Dysfunction Adult Information, Secondary Causes The OID for this table is 2.16.840.1.113883.12.9050. Table 5.14 GH Dysfunction Adult Information, Secondary Causes Code A O D O Description Age Obesity Depression Other Additional Comments If used, then Secondary Causes Other must be completed. 5.15 HL79051: Nutritional Information, Assessment Indicator The OID for this table is 2.16.840.1.113883.12.9051. Table 5.15 Nutritional Information, Assessment Indicator Code CMP PLD Description Completed Planned Additional Comments 5.16 HL79052: Parental Height, Availability Indicator The OID for this table is 2.16.840.1.113883.12.9052. Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page 61 November 2005 Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 Table 5.16 Parental Height, Availability Indicator Code MK FK BK BU Description Mother Known Father Known Both Known Both Unknown Additional Comments 5.17 HL79053: Diagnosis Confirmation and Level of Treatment Needed, Procedure Employed The OID for this table is 2.16.840.1.113883.12.9053. Table 5.17 Diagnosis Confirmation and Level Treatment Needed, Procedure Employed Code BMS EGD BIO Description Barium Studies Endoscopy Biopsy Additional Comments 5.18 HL79054: Diagnosis Confirmation and Level of Treatment Needed, GERD By Endoscopy Type The OID for this table is 2.16.840.1.113883.12.9054. Table 5.18 Diagnosis Confirmation and Level of Treatment Needed, GERD By Endoscopy Type Code ERSV1 ERSV2 ERSV3 ERSV4 NERSV Description Erosive Grade 1 Erosive Grade 2 Erosive Grade 3 Erosive Grade 4 Non Erosive Additional Comments 5.19 HL79055: H-Pylori Information, Status The OID for this table is 2.16.840.1.113883.12.9055. Table 5.19 H-Pylori Information, Status Code PS NE Description Positive Negative Additional Comments 5.20 HL79056: H-Pylori Information, Confirmed By The OID for this table is 2.16.840.1.113883.12.9056. Table 5.20 H-Pylori Information, Confirmed By Page 62 November 2005 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment Code SROL URBT FSGS B1HA SCST OTH Description Serology Urease Breath Test Feasting Serum Gastrin Basal 1 Hour Acid Output Secretion Simulation Test Other CDAR1AIS0010R010 Additional Comments If used, then H-Pylori Information Confirmed by Other is required. 5.21 HL79057: ED, Related Diagnosis Confirmation, Confirmed By The OID for this table is 2.16.840.1.113883.12.9057. Table 5.21 ED, Related Diagnosis Confirmation, Confirmed By Code TST PRL THY NA OTH Description Tertosterone Level Prolactin Level Thyroid Level Not Applicable Other Test Additional Comments If used, then ED, Related Diagnosis Confirmation, Confirmed By Other is required. 5.22 HL79058: ED, Patient History – Pulmonary Hypertension Functional Level The OID for this table is 2.16.840.1.113883.12.9058. Table 5.22 ED, Patient History – Pulmonary Hypertension Functional Level Code C1 C2 C3 C4 Description Class I Class II Class III Class IV Additional Comments 5.23 HL79059: ED, Patient History – Evaluation Type The OID for this table is 2.16.840.1.113883.12.9059. Table 5.23 ED, Patient History – Evaluation Type Code GH UC NA Description General Health Status Evaluation Investigation of Underlying Causes of Primary Condition Not Applicable Additional Comments 5.24 HL79060: ED, Patient History – ED Related To The OID for this table is 2.16.840.1.113883.12.9060. Table 5.24 ED, Patient History – ED Related To Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page 63 November 2005 Additional Information Specification 0010: PharmPA Attachment Code END URS SPC TSC PSG Description Endocrine Disorder Urogenital Surgery Spinal Cord Injury Testicular Cancer Psychogenic CDAR1AIS0010R010 Additional Comments 5.25 HL79061: ED, Treatment of Related Causes – Psychogenic Causes of ED Treatment The OID for this table is 2.16.840.1.113883.12.9061. Table 5.25 ED, Treatment of Related Causes – Psychogenic Causes of ED Treatment Code PSY BHT OTT NOT Description Psychotherapy Behavior Therapy Other Therapy No Treatment Additional Comments 5.26 HL79062: ED, Treatment of Related Causes – Drug Induced Option The OID for this table is 2.16.840.1.113883.12.9062. Table 5.26 ED, Treatment of Related Causes – Drug Induced Option Code RDU DCT CGD DCN Description Reduction in Drug Use Discontinue Drug Use Change Drug Drug Cannot be Change or Discontinued Additional Comments 5.27 HL79063: ED Concurrent Therapy, Type The OID for this table is 2.16.840.1.113883.12.9063. Table 5.27 ED Concurrent Therapy, Type Code NTT APB SRI PGN ETA VDP OED Description Nitrate Alpha-Blocker SSRI Prostaglandin for PPH Endothelium for PAH Vasodilator for PAH Other ED Medication Additional Comments If used, then ED Concurrent Therapy, Other Type is required. 5.28 HL79064: Narcotic (Opioid) Agonists, Patient History – Pain Syndrome Source The OID for this table is 2.16.840.1.113883.12.9064. Table 5.28 Narcotic (Opioid) Agonists, Patient History – Pain Syndrome Source Page 64 November 2005 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment Code BPN JPN MST VPN NPN OTH Description Bone Pain Joint Pain Other Somatic Pain (Muscle./Soft Tissue) Visceral Pain Neuropathic Pain Other Pain Syndrome CDAR1AIS0010R010 Additional Comments If used, then Pain Syndrome Other is required. 5.29 HL79065: Narcotic (Opioid) Agonists, Patient History – Pain Syndrome History The OID for this table is 2.16.840.1.113883.12.9065. Table 5.29 Narcotic (Opioid) Agonists, Patient History – Pain Syndrome History Code CP ITP ICP Description Constant Pain Intermittent Pain Incidental Pain Additional Comments 5.30 HL79066: Narcotic (Opioid) Agonists, Patient History – Pain Syndrome Persistence The OID for this table is 2.16.840.1.113883.12.9066. Table 5.30 Narcotic (Opioid) Agonists, Patient History – Pain Syndrome Persistance Code AL CR CRP CPR Description Acute Limited – Less Than 30 Days Chronic Chronic Progressive Chronic Progressive with Escalating Opioid Additional Comments 5.31 HL79067: Narcotic (Opioid) Agonists, Complicating Conditions The OID for this table is 2.16.840.1.113883.12.9067. Table 5.31 Narcotic (Opioid) Agonists, Complicating Conditions Code BRA PAI PSY LDY KDY CRP OTH Description Bronchial Asthma Paralytic Ileum Psychiatric Condition Liver Dysfunction Kidney Dysfunction Other Chronic Pulmonary Condition Other Additional Comments Diagnosed or suspected. If used, then Other Complicating Conditions is required 5.32 HL79068: Opioid Related Concurrent Pain Therapy, Opioid Level The OID for this table is 2.16.840.1.113883.12.9068. Table 5.32 Opioid Concurrent Pain Therapy, Opioid Level Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page 65 November 2005 Additional Information Specification 0010: PharmPA Attachment Code RDL HPL 24L OTL Description Recommended, Dose Level High Potency Dose Level 24 Hour High Potency Dose Level Opioid Tolerant CDAR1AIS0010R010 Additional Comments 5.33 HL79069: Drug Prescribed, Topical Therapy - Reason The OID for this table is 2.16.840.1.113883.12.9069. Table 5.33 Drug Prescribed, Topical Therapy - Reason Code UTS HDS OTH Description Unable to Swallow Hepatic Dysfunction Other Additional Comments 5.34 HL79070: Imidazole – Related Antifungals, Diagnosis Confirmed By The OID for this table is 2.16.840.1.113883.12.9070. Table 5.34 Imidazole – Related Antifungals, Diagnosis Confirmed By Code FCL PAS KOH NBP OTH Description Fungal Culture PAS Stain Results KOH Preparation Nail Biopsy Other Additional Comments 5.35 HL79071: Fungal Infection Information, Location The OID for this table is 2.16.840.1.113883.12.9071. Table 5.35 Fungal Infection Information, Location Code FN TN OTH Description Finger Nail Toe Nail Other Additional Comments 5.36 HL79072: Immune Compromise Information, Cause The OID for this table is 2.16.840.1.113883.12.9072. Table 5.36 Immune Compromise Information, Cause Code DIS TRP MED NA Description Disease Transplant Medical Intervention Not Applicable Additional Comments 5.37 HL79073: Immune Compromise Information, Verified By The OID for this table is 2.16.840.1.113883.12.9073. Table 5.37 Immune Compromise Information, Verified By Page 66 November 2005 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment Code CD4 ANC WBC Description CD4 Count ANC Count White Blood Cell Count CDAR1AIS0010R010 Additional Comments 5.38 HL79074: Co-Morbid Condition Information, Liver Dysfunction – Confirmed By The OID for this table is 2.16.840.1.113883.12.9074. Table 5.38 Co-Morbid Condition Information, Liver Dysfunction – Confirmed By Code HFP TAL TAS OTH Description Hepatic Function Panel SGPT, ALT SGOT, AST Other Additional Comments 5.39 HL79075: Level of Functional Impairment The OID for this table is 2.16.840.1.113883.12.9075. Table 5.39 Level of Functional Impairment Code AL CO DY EL PA Description Ambulation Limitations Contractures Dyspnea with Minimum Exertion Endurance Limitations Painful Ambulation Additional Comments 5.40 HL79076: Imidazole – Related Antifungals, Prior Therapy Type The OID for this table is 2.16.840.1.113883.12.9076. Table 5.40 Imidazole – Related Antifungals, Prior Therapy Type Code ORL TOP INJ IV Description Oral Topical Injectible Intravenous Additional Comments 5.41 I9C : ICD-9-CM International Classification of Diseases, 9th Clinical Modification. The OID for this table is 2.16.840.1.113883.6.2. 5.42 IC10: ICD-10-CM International Classification of Diseases, 10th Clinical Modification. The OID for this table is 2.16.840.1.113883.x.x. Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page 67 November 2005 Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 5.43 iso+: Extended ISO Units Codes ISO 2955-1983 and extensions as defined in HL7 Version 2.4 Figure 7-9. Due to its length the table is included in the HL7 Additional Information Specification Implementation Guide rather than in this Additional Information Specification. The OID for this table is 2.16.840.1.113883.6.2. 5.44 NDC: National Drug Code The National Drug Code (NDC), administered by the FDA, provides a unique code for each distinct drug, dose form, manufacturer, and package. (Available from the National Drug Code Director, FDA, Rockville, MD, and other sources.) The OID for this table is 2.16.840.1.113883.5.141. 5.45 RXNC: RxNorm SCD (Semantic Clinical Drug) RxNorm, a standardized nomenclature for clinical drugs, is produced by the National Library of Medicine. In this context, a clinical drug is a pharmaceutical product given to (or taken by) a patient with a therapeutic or diagnostic intent. In RxNorm, the name of a clinical drug combines its ingredients, strengths, and form. RxNorm follows a standard format in the naming of clinical drugs. Drugs named in disparate ways in various other vocabularies are normalized according to RxNorm’s naming conventions. RxNorm SCD includes ingredient plus strength and dose form. (Example: Fluoxetine 4 MG/ML Oral Solution). RxNorm can be obtained from the National Library of Medicine at: www.nlm.nih.gov. The OID for this table is 2.16.840.1.113883.5.x.xxx. 5.46 RXNB: RxNorm SBD (Semantic Branded Drug) RxNorm, a standardized nomenclature for clinical drugs, is produced by the National Library of Medicine. In this context, a clinical drug is a pharmaceutical product given to (or taken by) a patient with a therapeutic or diagnostic intent. In RxNorm, the name of a clinical drug combines its ingredients, strengths, and form. RxNorm follows a standard format in the naming of clinical drugs. Drugs named in disparate ways in various other vocabularies are normalized according to RxNorm’s naming conventions. RxNorm SBD includes ingredient, strength, and dose form plus brand name. ( Example: Fluoxetine 4 MG/ML Oral Solution [Prozac]). RxNorm can be obtained from the National Library of Medicine at: www.nlm.nih.gov. The OID for this table is 2.16.840.1.113883.x.xxx. 5.47 DEA: Drug Enforcement Administration [Change this description to describe the DEA Number and where to get more information on the DEA Number. See NDC] The US Drug Enforcement Administration is charged by statute the maintenance of controls against diversion of controlled substances and with the registration of all manufacturers and distributors of controlled substances and practitioners dispensing schedule III, IV or V drugs. The DEA number is assigned to practitioners meeting the criteria for dispensing, ordering and management of a patient on narcotic therapy. Page 68 November 2005 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 Further information and Application for a DEA number may be obtained at www.dea.gov Special DEA: Drug Enforcement Administration The US Drug Enforcement Administration is charged by statute the maintenance of controls against diversion of controlled substances and with the registration of all manufacturers and distributors of controlled substances and practitioners dispensing schedule III, IV or V drugs. The DEA number is assigned to practitioners meeting the criteria for dispensing, ordering and management of a patient on narcotic therapy. The Drug Addiction Treatment Act of 2000 (DATA2000) allows qualified physicians to practice medication-assisted opioid addiction therapy with specifically FDA-approved Schedule III, IV or V narcotic medications. The practitioner must submit a notice of intent to the Center for Substance Abuse Treatment (CSAT) a component of the Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services. Upon approval the DEA assigns a special identification number in addition to the practitioner’s regular DEA number. To obtain further information contact www.samhsa.gov and search waiver qualifications. Further information and Application for a DEA number may be obtained at www.dea.gov. The OID for this table is 2.16.840.1.113883.x.xxx. 5.48 HCI: HCIdea HCIdea™ is an NCPDP prescriber identity management database solution designed to address the needs of organizations wishing to identify prescribers of drugs. An NCPDP HCIdea™ Prescriber Identity Layout is available upon request. For information about obtaining the NCPDP HCIdea™ file and the current (version 1.1) file format, please contact Robin Ebert at 480-477-1000, ext. 118 or [email protected] Contact Information National Council of Prescription Drug Programs (NCPDP) 9240 East Raintree Drive Scottsdale, AZ 85260 (480) 477-1000 (480) 767-1042 (fax) The OID for this table is 2.16.840.1.113883.x.xxx. 5.49 NPI: National Provider Identifier On January 23, 2004, the Secretary of HHS published a final rule (Federal Register volume 69, page 3434) which establishes the standard for a unique health identifier for health care providers for use in the health care system, and announces the adoption of the National Provider Identifier (NPI) as that standard. It also establishes the implementation specifications for obtaining and using the standard unique health identifier for health care providers. For more information contact the US Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), 7500 Security Blvd., Baltimore, MD 21244 The DHHS Administrative Simplification web site is http://aspe.hhs.gov/admnsimp . Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard Page 69 November 2005 Additional Information Specification 0010: PharmPA Attachment CDAR1AIS0010R010 The OID for this table is 2.16.840.1.113883.4.6 5.50 PTX: Health Care Provider Taxonomy The National Uniform Claim Committee (NUCC) maintains the Health Care Provider Taxonomy. The code set is available through Washington Publishing. See: http://www.wpc-edi.com/codes/ The OID for this table is 2.16.840.1.113883.6.101. 5.51 Miscellaneous OID References This section contains a list of OID references used in the construct of the CDA header and body not otherwise noted in the above code set and table references. 5.51.1 Unique Instance Identifier The OID 2.16.840.1.113883.3.933 is used to identify the “unique instance ID” for this document. 5.51.2 person_name.type_cd OID 2.16.840.1.113883.12.200 is an object identifier for the person_name.type_cd component. 5.51.3 Proprietary Provider ID OID 2.16.840.1.113883.12.200 is an object identifier for the person_name.type_cd component. 5.51.4 Example OID In some instances in the example, OID 2.16.840.1.113883.19.7.xxx was used where xxx represents an author assigned number. This is used for demonstration purposes only. The actual OID for that concept will be included in the final published version of the document. --End of document-- Page 70 November 2005 Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved. Release 1.0 Draft Standard