LinuxForHealth FHIR Implementation Guide
8.0.0 - draft
LinuxForHealth FHIR Implementation Guide - Local Development build (v8.0.0). See the Directory of published versions
<Claim xmlns="http://hl7.org/fhir">
<id value="CDMClaimFacilityInstance"/>
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<valueString value="tenant7209"/>
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<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/ingestion-batch-id">
<valueString value="rgVCJnQBxvghkKTI8Hzz"/>
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<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-name">
<valueString value="TREX"/>
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<extension
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<valueString value="7209"/>
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url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-record-id">
<valueIdentifier>
<system value="http://acme-health.com/WellnessMedicalFacility"/>
<value value="7209_07869_e00080779_3938586_2516181"/>
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<extension
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<valueString value="e00030779"/>
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<source value="http://acme-health.com/WellnessMedicalFacility"/>
<profile
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<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: Claim</b><a name="CDMClaimFacilityInstance"> </a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource Claim "CDMClaimFacilityInstance" </p><p style="margin-bottom: 0px">Information Source: http://acme-health.com/WellnessMedicalFacility!</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-cdm-claim-facility.html">CDM Claim Facility</a></p></div><p><b>Admit Count</b>: 1</p><p><b>Aggregate Claim Indicator</b>: N</p><p><b>Claim Category</b>: F0 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (claim-status-category-codes#F0)</span></p><p><b>Claim Status</b>: F0 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (claim-status-codes#F0)</span></p><p><b>Claim Snapshot Provider Name</b>: Dr Smith</p><p><b>Claim Snapshot Provider Zip Code</b>: 79912</p><p><b>Employer</b>: EmployerCode <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (local-employer-code#EmployerCode)</span></p><p><b>Employee Business Unit</b>: EmpBusUnit <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (local-employee-business-unit#EmpBusUnit)</span></p><p><b>Financial System</b>: LocFinanceSys <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (local-financial-system#LocFinanceSys)</span></p><p><b>Last Claim Indicator</b>: Y</p><p><b>Participating Plan</b>: LocParticipatingPlan <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (local-participating-plan#LocParticipatingPlan)</span></p><p><b>Referral Indicator</b>: N</p><p><b>Snapshot Age In Years</b>: 20</p><p><b>Submission Type</b>: SubmitType <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (local-submission-type#SubmitType)</span></p><p><b>Payer PCP Responsibility Indicator</b>: N</p><p><b>identifier</b>: Source System Row Identifier: 000000000000000000019721078(use: OFFICIAL), Source System Row Identifier: 99999999999(use: SECONDARY)</p><p><b>status</b>: active</p><p><b>type</b>: Medical claim; Institutional/Professional unknown <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-payer-claim-type.html">Payer Claim Type Codes</a>#medical; local-claim-type#Medical)</span></p><p><b>subType</b>: Emergency <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-claim-subtype.html">Claim Subtype Codes</a>#emergency)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href="Patient-CDMPatientInstance.html">Patient/CDMPatientInstance</a> " MCLASTNAME"</p><p><b>billablePeriod</b>: 2017-06-02 --> 2017-06-02</p><p><b>created</b>: 2017-07-25 05:31:00-0500</p><p><b>provider</b>: <a href="Organization-Provider1.html">Organization/Provider1</a> "Dr Smith"</p><p><b>priority</b>: Normal <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-processpriority.html">Process Priority Codes</a>#normal)</span></p><p><b>referral</b>: <a href="ServiceRequest-CDMServiceRequestInstance.html">ServiceRequest/CDMServiceRequestInstance</a></p><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 1</p><p><b>provider</b>: <a href="Practitioner-DrKelly.html">Practitioner/DrKelly</a> " KELLY"</p><p><b>role</b>: Ordering provider <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-claim-care-team-role.html">Claim Care Team Role Codes</a>#ordering)</span></p></blockquote><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 2</p><p><b>provider</b>: <a href="Practitioner-DrSmith.html">Practitioner/DrSmith</a> " SMITH"</p><p><b>role</b>: Admitting provider <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-claim-care-team-role.html">Claim Care Team Role Codes</a>#admitting)</span></p></blockquote><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 3</p><p><b>provider</b>: <a href="Practitioner-DrKelly.html">Practitioner/DrKelly</a> " KELLY"</p><p><b>role</b>: Attending provider <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-claim-care-team-role.html">Claim Care Team Role Codes</a>#attending)</span></p></blockquote><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 4</p><p><b>provider</b>: <a href="Organization-Provider1.html">Organization/Provider1</a> "Dr Smith"</p><p><b>role</b>: Servicing provider <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-claim-care-team-role.html">Claim Care Team Role Codes</a>#servicing)</span></p><p><b>qualification</b>: 01 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (local-specialty#01)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 1</p><p><b>category</b>: Information <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html">Claim Information Category Codes</a>#info)</span></p><p><b>code</b>: Capitated service indicator <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-claim-supporting-info-type.html">Claim Supporting Info Type Codes</a>#capitated-service-indicator)</span></p><p><b>value</b>: N</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: Other <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html">Claim Information Category Codes</a>#other)</span></p><p><b>code</b>: Emergency Room <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-er-or-observation-room-service.html">Er Or Observation Room Service Codes</a>#1)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: Hospitalized <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html">Claim Information Category Codes</a>#hospitalized)</span></p><p><b>timing</b>: 2017-06-02 --> 2017-06-02</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 4</p><p><b>category</b>: Hospitalized <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html">Claim Information Category Codes</a>#hospitalized)</span></p><p><b>code</b>: Emergency <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-ub04-admit-type.html">UB04 Admit Type Code System</a>#1)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 5</p><p><b>category</b>: Hospitalized <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html">Claim Information Category Codes</a>#hospitalized)</span></p><p><b>code</b>: Hospital / Level I Intermediate Care / Admit Through Discharge Claim <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-ub04-admit-bill-type.html">UB04 Admit Bill Type Code System</a>#0151)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 6</p><p><b>category</b>: Hospitalized <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html">Claim Information Category Codes</a>#hospitalized)</span></p><p><b>code</b>: Days count <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-claim-supporting-info-type.html">Claim Supporting Info Type Codes</a>#days-count)</span></p><p><b>value</b>: 3 /d</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 7</p><p><b>category</b>: Discharge <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html">Claim Information Category Codes</a>#discharge)</span></p><p><b>code</b>: 11 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (patient-discharge#11)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 8</p><p><b>category</b>: Other <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html">Claim Information Category Codes</a>#other)</span></p><p><b>code</b>: Room and Board <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-room-and-board-service.html">Room And Board Service Codes</a>#1)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 9</p><p><b>category</b>: Information <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html">Claim Information Category Codes</a>#info)</span></p><p><b>code</b>: Network provider indicator <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-claim-supporting-info-type.html">Claim Supporting Info Type Codes</a>#network-provider-indicator)</span></p><p><b>value</b>: Y</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 10</p><p><b>category</b>: Hospitalized <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html">Claim Information Category Codes</a>#hospitalized)</span></p><p><b>code</b>: Admission hour <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-claim-supporting-info-type.html">Claim Supporting Info Type Codes</a>#admission-hour)</span></p><p><b>value</b>: 07</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 11</p><p><b>category</b>: Hospitalized <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html">Claim Information Category Codes</a>#hospitalized)</span></p><p><b>code</b>: Days count <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-claim-supporting-info-type.html">Claim Supporting Info Type Codes</a>#days-count)</span></p><p><b>value</b>: 3 /d</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 12</p><p><b>category</b>: Hospitalized <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html">Claim Information Category Codes</a>#hospitalized)</span></p><p><b>code</b>: Days not covered <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-claim-supporting-info-type.html">Claim Supporting Info Type Codes</a>#days-not-covered)</span></p><p><b>value</b>: 1 /d</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 13</p><p><b>category</b>: Hospitalized <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html">Claim Information Category Codes</a>#hospitalized)</span></p><p><b>code</b>: Days longterm care recipient on leave <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-claim-supporting-info-type.html">Claim Supporting Info Type Codes</a>#days-long-term-care-recipient-on-leave)</span></p><p><b>value</b>: 0 /d</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 14</p><p><b>category</b>: Hospitalized <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html">Claim Information Category Codes</a>#hospitalized)</span></p><p><b>code</b>: Newbord length of stay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-claim-supporting-info-type.html">Claim Supporting Info Type Codes</a>#newborn-length-of-stay)</span></p><p><b>value</b>: 0 /d</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 15</p><p><b>category</b>: Information <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html">Claim Information Category Codes</a>#info)</span></p><p><b>code</b>: Onset of symptoms/illness <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-v2-0350.html">nubc-OccurrenceCode-cs</a>#11)</span></p><p><b>timing</b>: 2017-06-02 --> 2017-06-02</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 16</p><p><b>category</b>: Information <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html">Claim Information Category Codes</a>#info)</span></p><p><b>code</b>: Acquired Condition Indicator <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-claim-supporting-info-type.html">Claim Supporting Info Type Codes</a>#acquired-condition-indicator)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 17</p><p><b>category</b>: Hospitalized <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html">Claim Information Category Codes</a>#hospitalized)</span></p><p><b>code</b>: Discharge hour <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-claim-supporting-info-type.html">Claim Supporting Info Type Codes</a>#discharge-hour)</span></p><p><b>value</b>: 22</p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 1</p><p><b>diagnosis</b>: Headache <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-icd10CM.html">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#R51)</span></p><p><b>type</b>: Principal Diagnosis <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-ex-diagnosistype.html">Example Diagnosis Type Codes</a>#principal)</span></p><p><b>onAdmission</b>: Yes, present ad admission <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-diagnosis-present-on-admission.html">Diagnosis Present On Admission Codes</a>#Y)</span></p><p><b>packageCode</b>: 102 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (P0002.html#102)</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 2</p><p><b>diagnosis</b>: Migraine, Unspecified, not Intractable, without Status Migrainosus <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-icd10CM.html">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#G43.909)</span></p><p><b>type</b>: Discharge Diagnosis <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-ex-diagnosistype.html">Example Diagnosis Type Codes</a>#discharge)</span></p><p><b>onAdmission</b>: No, not present at admission <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-diagnosis-present-on-admission.html">Diagnosis Present On Admission Codes</a>#N)</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 3</p><p><b>diagnosis</b>: Migraine, unspecified <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-icd10CM.html">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#G43.9)</span></p><p><b>type</b>: Admitting Diagnosis <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-ex-diagnosistype.html">Example Diagnosis Type Codes</a>#admitting)</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 4</p><p><b>diagnosis</b>: Fall on and from ladder, initial encounter <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-icd10CM.html">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#W11.XXXA)</span></p><p><b>type</b>: External Cause <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-diagnosis-type.html">Diagnosis Type Codes</a>#external-cause)</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 1</p><p><b>type</b>: surgical <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-procedure-type.html">Procedure Type Codes</a>#surgical)</span></p><p><b>procedure</b>: Special EEG Tests <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#95958)</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 2</p><p><b>type</b>: surgical <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-procedure-type.html">Procedure Type Codes</a>#surgical)</span></p><p><b>procedure</b>: Autologous blood or component, collection processing and storage <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#86891)</span></p></blockquote><h3>Insurances</h3><table class="grid"><tr><td>-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Identifier</b></td><td><b>Coverage</b></td><td><b>PreAuthRef</b></td></tr><tr><td>*</td><td>, </td><td>1</td><td>true</td><td>id: PPOB</td><td><a href="Coverage-CoverageExample.html">Coverage/CoverageExample</a></td><td>PreAuth12345</td></tr></table><h3>Accidents</h3><table class="grid"><tr><td>-</td><td><b>Date</b></td><td><b>Type</b></td></tr><tr><td>*</td><td>1900-01-01</td><td>No <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-payer-indicators.html">Payer Indicator Codes</a>#N)</span></td></tr></table><h3>Items</h3><table class="grid"><tr><td>-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>CareTeamSequence</b></td><td><b>Revenue</b></td><td><b>ProductOrService</b></td><td><b>Modifier</b></td><td><b>Serviced[x]</b></td><td><b>Location[x]</b></td><td><b>Quantity</b></td></tr><tr><td>*</td><td>, , , </td><td>1</td><td>2</td><td>Emergency Room <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (RevenueCodes#0450)</span></td><td>superficial muscle biopsy <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#20200; local-service-type#LocalServiceType)</span></td><td>Primary physician <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-procedure-modifier.html">Procedure Modifier Codes</a>#AG)</span></td><td>2017-06-02</td><td>Office <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-CMSPlaceofServiceCodes.html">CMS Place of Service Codes (POS)</a>#11; local-place-of-service#LocalPlcOfService)</span></td><td>3</td></tr></table></div>
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</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/employee-business-unit">
<valueCodeableConcept>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-employee-business-unit"/>
<code value="EmpBusUnit"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/financial-system">
<valueCodeableConcept>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-financial-system"/>
<code value="LocFinanceSys"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/last-claim-indicator">
<valueString value="Y"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/participating-plan">
<valueCodeableConcept>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-participating-plan"/>
<code value="LocParticipatingPlan"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/referral-indicator">
<valueString value="N"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/snapshot-age-in-years">
<valueUnsignedInt value="20"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/submission-type">
<valueCodeableConcept>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-submission-type"/>
<code value="SubmitType"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/payer-pcp-responsibility-indicator">
<valueString value="N"/>
</extension>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/identifier-type"/>
<code value="SSRI"/>
</coding>
</type>
<system value="http://acme-health.com/CodeSystem/local-claim-identifier"/>
<value value="000000000000000000019721078"/>
<assigner>
<display value="Acme Health - Wellness Medical Facility"/>
</assigner>
</identifier>
<identifier>
<use value="secondary"/>
<type>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/identifier-type"/>
<code value="SSRI"/>
</coding>
</type>
<system
value="http://acme-health.com/CodeSystem/local-authorization-identifier"/>
<value value="99999999999"/>
<assigner>
<display
value="Acme Health - Wellness Medical Facility Corporate Office"/>
</assigner>
</identifier>
<status value="active"/>
<type>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/payer-claim-type"/>
<code value="medical"/>
</coding>
<coding>
<system value="http://acme-health.com/CodeSystem/local-claim-type"/>
<code value="Medical"/>
</coding>
</type>
<subType>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-subtype"/>
<code value="emergency"/>
</coding>
</subType>
<use value="claim"/>
<patient>
<reference value="Patient/CDMPatientInstance"/>
</patient>
<billablePeriod>
<start value="2017-06-02"/>
<end value="2017-06-02"/>
</billablePeriod>
<created value="2017-07-25T17:31:00-05:00"/>
<provider>
<reference value="Organization/Provider1"/>
</provider>
<priority>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
</coding>
</priority>
<referral>
<reference value="ServiceRequest/CDMServiceRequestInstance"/>
</referral>
<careTeam>
<sequence value="1"/>
<provider>
<reference value="Practitioner/DrKelly"/>
</provider>
<role>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-care-team-role"/>
<code value="ordering"/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value="2"/>
<provider>
<reference value="Practitioner/DrSmith"/>
</provider>
<role>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-care-team-role"/>
<code value="admitting"/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value="3"/>
<provider>
<reference value="Practitioner/DrKelly"/>
</provider>
<role>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-care-team-role"/>
<code value="attending"/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value="4"/>
<provider>
<reference value="Organization/Provider1"/>
</provider>
<role>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-care-team-role"/>
<code value="servicing"/>
</coding>
</role>
<qualification>
<coding>
<system value="http://acme-health.com/CodeSystem/local-specialty"/>
<code value="01"/>
</coding>
</qualification>
</careTeam>
<supportingInfo>
<sequence value="1"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="info"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type"/>
<code value="capitated-service-indicator"/>
</coding>
</code>
<valueString value="N"/>
</supportingInfo>
<supportingInfo>
<sequence value="2"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="other"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/er-or-observation-room-service"/>
<code value="1"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="3"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="hospitalized"/>
</coding>
</category>
<timingPeriod>
<start value="2017-06-02"/>
<end value="2017-06-02"/>
</timingPeriod>
</supportingInfo>
<supportingInfo>
<sequence value="4"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="hospitalized"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/ub04-admit-type"/>
<code value="1"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="5"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="hospitalized"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/ub04-admit-bill-type"/>
<code value="0151"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="6"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="hospitalized"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type"/>
<code value="days-count"/>
</coding>
</code>
<valueQuantity>
<value value="3"/>
<unit value="/d"/>
<system value="http://unitsofmeasure.org"/>
</valueQuantity>
</supportingInfo>
<supportingInfo>
<sequence value="7"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="discharge"/>
</coding>
</category>
<code>
<coding>
<system value="https://www.nubc.org/patient-discharge"/>
<code value="11"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="8"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="other"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/room-and-board-service"/>
<code value="1"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="9"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="info"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type"/>
<code value="network-provider-indicator"/>
</coding>
</code>
<valueString value="Y"/>
</supportingInfo>
<supportingInfo>
<sequence value="10"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="hospitalized"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type"/>
<code value="admission-hour"/>
</coding>
</code>
<valueString value="07"/>
</supportingInfo>
<supportingInfo>
<sequence value="11"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="hospitalized"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type"/>
<code value="days-count"/>
</coding>
</code>
<valueQuantity>
<value value="3"/>
<unit value="/d"/>
<system value="http://unitsofmeasure.org"/>
</valueQuantity>
</supportingInfo>
<supportingInfo>
<sequence value="12"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="hospitalized"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type"/>
<code value="days-not-covered"/>
</coding>
</code>
<valueQuantity>
<value value="1"/>
<unit value="/d"/>
<system value="http://unitsofmeasure.org"/>
</valueQuantity>
</supportingInfo>
<supportingInfo>
<sequence value="13"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="hospitalized"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type"/>
<code value="days-long-term-care-recipient-on-leave"/>
</coding>
</code>
<valueQuantity>
<value value="0"/>
<unit value="/d"/>
<system value="http://unitsofmeasure.org"/>
</valueQuantity>
</supportingInfo>
<supportingInfo>
<sequence value="14"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="hospitalized"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type"/>
<code value="newborn-length-of-stay"/>
</coding>
</code>
<valueQuantity>
<value value="0"/>
<unit value="/d"/>
<system value="http://unitsofmeasure.org"/>
</valueQuantity>
</supportingInfo>
<supportingInfo>
<sequence value="15"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="info"/>
</coding>
</category>
<code>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0350"/>
<code value="11"/>
</coding>
</code>
<timingPeriod>
<start value="2017-06-02"/>
<end value="2017-06-02"/>
</timingPeriod>
</supportingInfo>
<supportingInfo>
<sequence value="16"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="info"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type"/>
<code value="acquired-condition-indicator"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="17"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="hospitalized"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type"/>
<code value="discharge-hour"/>
</coding>
</code>
<valueString value="22"/>
</supportingInfo>
<diagnosis>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="R51"/>
<display value="Headache"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
<code value="principal"/>
</coding>
</type>
<onAdmission>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/diagnosis-present-on-admission"/>
<code value="Y"/>
</coding>
</onAdmission>
<packageCode>
<coding>
<system
value="https://www.cms.gov/icd10m/version37-fullcode-cms/fullcode_cms/P0002.html"/>
<code value="102"/>
</coding>
</packageCode>
</diagnosis>
<diagnosis>
<sequence value="2"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="G43.909"/>
<display
value="Migraine, Unspecified, not Intractable, without Status Migrainosus"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
<code value="discharge"/>
</coding>
</type>
<onAdmission>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/diagnosis-present-on-admission"/>
<code value="N"/>
</coding>
</onAdmission>
</diagnosis>
<diagnosis>
<sequence value="3"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="G43.9"/>
<display value="Migraine, unspecified"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
<code value="admitting"/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="4"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="W11.XXXA"/>
<display value="Fall on and from ladder, initial encounter"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/diagnosis-type"/>
<code value="external-cause"/>
</coding>
</type>
</diagnosis>
<procedure>
<sequence value="1"/>
<type>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/procedure-type"/>
<code value="surgical"/>
</coding>
</type>
<procedureCodeableConcept>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="95958"/>
<display value="Special EEG Tests"/>
</coding>
</procedureCodeableConcept>
</procedure>
<procedure>
<sequence value="2"/>
<type>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/procedure-type"/>
<code value="surgical"/>
</coding>
</type>
<procedureCodeableConcept>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="86891"/>
<display
value="Autologous blood or component, collection processing and storage"/>
</coding>
</procedureCodeableConcept>
</procedure>
<insurance>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/crossover-indicator">
<valueString value="N"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/prior-authorization-indicator">
<valueString value="Y"/>
</extension>
<sequence value="1"/>
<focal value="true"/>
<identifier>
<system value="http://acme-health.com/BCBS"/>
<value value="PPOB"/>
</identifier>
<coverage>
<reference value="Coverage/CoverageExample"/>
</coverage>
<preAuthRef value="PreAuth12345"/>
</insurance>
<accident>
<date value="1900-01-01"/>
<type>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/payer-indicators"/>
<code value="N"/>
</coding>
</type>
</accident>
<item>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/capitated-service-indicator">
<valueString value="N"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/fully-insured-indicator">
<valueString value="Y"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/nursing-home-indicator">
<valueString value="N"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/service-bill-days-count">
<valueUnsignedInt value="20"/>
</extension>
<sequence value="1"/>
<careTeamSequence value="2"/>
<revenue>
<coding>
<system value="https://www.nubc.org/RevenueCodes"/>
<code value="0450"/>
<display value="Emergency Room"/>
</coding>
</revenue>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="20200"/>
<display value="superficial muscle biopsy"/>
</coding>
<coding>
<system value="http://acme-health.com/CodeSystem/local-service-type"/>
<code value="LocalServiceType"/>
</coding>
</productOrService>
<modifier>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/procedure-modifier"/>
<code value="AG"/>
</coding>
</modifier>
<servicedDate value="2017-06-02"/>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="11"/>
<display value="Office"/>
</coding>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-place-of-service"/>
<code value="LocalPlcOfService"/>
</coding>
</locationCodeableConcept>
<quantity>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/local-number-of-units-per-service">
<valueQuantity>
<value value="5"/>
</valueQuantity>
</extension>
<value value="3"/>
</quantity>
</item>
</Claim>
IG © 2021+ LinuxForHealth Team. Package linuxforhealth.fhir.ig#8.0.0 based on FHIR 4.0.1. Generated 2022-11-10
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