Download Drug Prior Authorization Attachment AIS

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
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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.
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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
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Copyright © 1998-2005 Health Level Seven, Inc. All rights reserved.
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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.
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2005
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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
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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
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Additional Information Specification 0010: PharmPA Attachment
1.1
CDAR1AIS0010R010
LOINC Codes and Structure
LOINC codes are used for several purposes:
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
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.
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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
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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.
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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 .
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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--
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