Terminology Owner/Contact Current Procedures Terminology (CPT) code set American Medical Association SNOMED CT International Healthcare Terminology Standards Developing Organization (IHTSDO) or info@ihtsdo.org Logical Observation Identifiers Names & Codes (LOINC) Regenstrief Institute International Classification of Diseases (ICD) codes World Health Organization (WHO) NUCC Health Care Provider Taxonomy code set American Medical Association. Please see 222.nucc.org. AMA licensing contact: 312-464-5022 (AMA IP services) of Contents Trial
documents, and entries within those sections are explained as described in Sections 1-4 of the C-CDA R2.1: Volume 2 Templates and Supporting Material. C.3 LOINC Codes The following shows the recommended LOINC codes for the C-CDA R2.1 structured documents. These codes should be used to request a “clinical” document and to identify such a document when it is submitted. Table 6: C-CDA R2.1 Clinical Document Types with Recommended LOINC Code for Requests Clinical Document Type LOINC LOINC Long Description C-CDA R2.1 Table ValueSet Care Plan 52521-2 Overall Plan of Care/Advance Care Directive _ No value set Consultation Note 11488-4 Consult Note Table #28 ConsultDocumentType CCD 34133-9 Summarization of Episode Note _ No set Diagnostic Imaging Report 18748-4 Diagnostic imaging Report _ LOINC Imaging Document Codes Discharge Summary 18842-5 Discharge Summary Table #37 DischargeSummaryTypeCode History and Physical 34117-2 History and Physical note #41 HPDocumentType Operative Note 11504-8 Unspecified Operation Note Table #44 Procedure Note 28570-0 Unspecified Procedure Note Table #48 Progress Note Unspecified Progress Note Table# 51 ProgressNoteDocumentTypeCode Referral Note 57133-1 Referral Note Table# 54 ReferralDocumentType Transfer Summary 18761-7 Unspecified Transfer Summary Table# 57 TransferDocumentType The requester may request a document that conforms to a specific implementation guide (e.g. C-CDA R2.1 or C-CDA R1.1) by specifying the appropriate modifier code for that implemenation guide. Clinical Documents for Payers Set 1 Release 1.1
Table 9: XD* Submission Set Metadata S.No Existing or Extension XD* Metadata Attribute Definition Data Type Required 1 Existing Author Represents the humans and/or machines that authored the document. This attribute contains the following sub-attributes: authorInstitution, authorPerson, authorRole, authorSpecialty, authorTelecommunication R2 1.1 Existing of author) XON.1 - Name of the Provider or Agent sending the request XON.10 - ID of the Provider or Agent sending the request XON R2 1.2 Existing authorPerson (sub-attribute of author) Contact person for administrative questions XCN.2 - Last Name XCN.3 - First Name XCN.4 - Middle Name XCN.5 - Suffix XCN.6 - Prefix XCN O 1.3 Existing for esMD administrative questions XTN.1 - [NNN] [(999)]999-9999 [X99999] [B99999] [C any text] XTN.4 - Email Address XTN.6 - area code XTN.7 - phone number XTN.8 - extension XTN O 2 Existing Comments Description of reason for the replacement, follow up, or termination for a prior request O 3 Existing The code specifying the type of clinical activity that resulted in placing these XDS Documents in this XDS-Submission Set. These values are to be drawn for a vocabulary defined by the XDS Affinity Domain. R2 4 Existing R2 5 Existing entryUUID A unique ID or a globally unique identifier within the document submission request for the SubmissionSet. Intervening portal generates this as part of generating the XDR/XDM message UUID R