Generated Narrative: Claim

Admit Count: 1

Aggregate Claim Indicator: N

Claim Category: F0 (claim-status-category-codes#F0)

Claim Status: F0 (claim-status-codes#F0)

Claim Snapshot Provider Name: Dr Smith

Claim Snapshot Provider Zip Code: 79912

Employer: EmployerCode (local-employer-code#EmployerCode)

Employee Business Unit: EmpBusUnit (local-employee-business-unit#EmpBusUnit)

Financial System: LocFinanceSys (local-financial-system#LocFinanceSys)

Last Claim Indicator: Y

Participating Plan: LocParticipatingPlan (local-participating-plan#LocParticipatingPlan)

Referral Indicator: N

Snapshot Age In Years: 20

Submission Type: SubmitType (local-submission-type#SubmitType)

Payer PCP Responsibility Indicator: N

identifier: Source System Row Identifier: 000000000000000000019721078(use: OFFICIAL), Source System Row Identifier: 99999999999(use: SECONDARY)

status: active

type: Medical claim; Institutional/Professional unknown (Payer Claim Type Codes#medical; local-claim-type#Medical)

subType: Emergency (Claim Subtype Codes#emergency)

use: claim

patient: Patient/CDMPatientInstance " MCLASTNAME"

billablePeriod: 2017-06-02 --> 2017-06-02

created: 2017-07-25 05:31:00-0500

provider: Organization/Provider1 "Dr Smith"

priority: Normal (Process Priority Codes#normal)

referral: ServiceRequest/CDMServiceRequestInstance

careTeam

sequence: 1

provider: Practitioner/DrKelly " KELLY"

role: Ordering provider (Claim Care Team Role Codes#ordering)

careTeam

sequence: 2

provider: Practitioner/DrSmith " SMITH"

role: Admitting provider (Claim Care Team Role Codes#admitting)

careTeam

sequence: 3

provider: Practitioner/DrKelly " KELLY"

role: Attending provider (Claim Care Team Role Codes#attending)

careTeam

sequence: 4

provider: Organization/Provider1 "Dr Smith"

role: Servicing provider (Claim Care Team Role Codes#servicing)

qualification: 01 (local-specialty#01)

supportingInfo

sequence: 1

category: Information (Claim Information Category Codes#info)

code: Capitated service indicator (Claim Supporting Info Type Codes#capitated-service-indicator)

value: N

supportingInfo

sequence: 2

category: Other (Claim Information Category Codes#other)

code: Emergency Room (Er Or Observation Room Service Codes#1)

supportingInfo

sequence: 3

category: Hospitalized (Claim Information Category Codes#hospitalized)

timing: 2017-06-02 --> 2017-06-02

supportingInfo

sequence: 4

category: Hospitalized (Claim Information Category Codes#hospitalized)

code: Emergency (UB04 Admit Type Code System#1)

supportingInfo

sequence: 5

category: Hospitalized (Claim Information Category Codes#hospitalized)

code: Hospital / Level I Intermediate Care / Admit Through Discharge Claim (UB04 Admit Bill Type Code System#0151)

supportingInfo

sequence: 6

category: Hospitalized (Claim Information Category Codes#hospitalized)

code: Days count (Claim Supporting Info Type Codes#days-count)

value: 3 /d

supportingInfo

sequence: 7

category: Discharge (Claim Information Category Codes#discharge)

code: 11 (patient-discharge#11)

supportingInfo

sequence: 8

category: Other (Claim Information Category Codes#other)

code: Room and Board (Room And Board Service Codes#1)

supportingInfo

sequence: 9

category: Information (Claim Information Category Codes#info)

code: Network provider indicator (Claim Supporting Info Type Codes#network-provider-indicator)

value: Y

supportingInfo

sequence: 10

category: Hospitalized (Claim Information Category Codes#hospitalized)

code: Admission hour (Claim Supporting Info Type Codes#admission-hour)

value: 07

supportingInfo

sequence: 11

category: Hospitalized (Claim Information Category Codes#hospitalized)

code: Days count (Claim Supporting Info Type Codes#days-count)

value: 3 /d

supportingInfo

sequence: 12

category: Hospitalized (Claim Information Category Codes#hospitalized)

code: Days not covered (Claim Supporting Info Type Codes#days-not-covered)

value: 1 /d

supportingInfo

sequence: 13

category: Hospitalized (Claim Information Category Codes#hospitalized)

code: Days longterm care recipient on leave (Claim Supporting Info Type Codes#days-long-term-care-recipient-on-leave)

value: 0 /d

supportingInfo

sequence: 14

category: Hospitalized (Claim Information Category Codes#hospitalized)

code: Newbord length of stay (Claim Supporting Info Type Codes#newborn-length-of-stay)

value: 0 /d

supportingInfo

sequence: 15

category: Information (Claim Information Category Codes#info)

code: Onset of symptoms/illness (nubc-OccurrenceCode-cs#11)

timing: 2017-06-02 --> 2017-06-02

supportingInfo

sequence: 16

category: Information (Claim Information Category Codes#info)

code: Acquired Condition Indicator (Claim Supporting Info Type Codes#acquired-condition-indicator)

supportingInfo

sequence: 17

category: Hospitalized (Claim Information Category Codes#hospitalized)

code: Discharge hour (Claim Supporting Info Type Codes#discharge-hour)

value: 22

diagnosis

sequence: 1

diagnosis: Headache (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#R51)

type: Principal Diagnosis (Example Diagnosis Type Codes#principal)

onAdmission: Yes, present ad admission (Diagnosis Present On Admission Codes#Y)

packageCode: 102 (P0002.html#102)

diagnosis

sequence: 2

diagnosis: Migraine, Unspecified, not Intractable, without Status Migrainosus (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#G43.909)

type: Discharge Diagnosis (Example Diagnosis Type Codes#discharge)

onAdmission: No, not present at admission (Diagnosis Present On Admission Codes#N)

diagnosis

sequence: 3

diagnosis: Migraine, unspecified (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#G43.9)

type: Admitting Diagnosis (Example Diagnosis Type Codes#admitting)

diagnosis

sequence: 4

diagnosis: Fall on and from ladder, initial encounter (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#W11.XXXA)

type: External Cause (Diagnosis Type Codes#external-cause)

procedure

sequence: 1

type: surgical (Procedure Type Codes#surgical)

procedure: Special EEG Tests (Current Procedural Terminology (CPT®)#95958)

procedure

sequence: 2

type: surgical (Procedure Type Codes#surgical)

procedure: Autologous blood or component, collection processing and storage (Current Procedural Terminology (CPT®)#86891)

Insurances

Accidents

Items