/
Multiple CPT E&M Codes Single Encounter(C-CDAR2.1).xml
143 lines (142 loc) · 11.7 KB
/
Multiple CPT E&M Codes Single Encounter(C-CDAR2.1).xml
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.22" assigningAuthorityName="CCDA Encounters Section" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.2.22" assigningAuthorityName="CCDA Encounters Section" />
<id root="6c628dae-578b-4e3a-b0d9-e82453d29c14" />
<code code="46240-8" displayName="History of encounters" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
<title>Encounters</title>
<text>
<table width="100%">
<thead>
<tr>
<th>Encounter</th>
<th>Provider</th>
<th>Location</th>
<th>Date</th>
<th>Diagnosis</th>
</tr>
</thead>
<tbody>
<tr ID="encounterDescriptionID0">
<td ID="encounterTypeDescriptionID0">Wellness Visit</td>
<td>David E Ford MD</td>
<td>
</td>
<td>09/18/2017</td>
<td><content ID="encounterDiagnosisID0">Jaw Asymmetry Maxillary</content>, <content ID="encounterDiagnosisID1">Anomaly of Dental Arch</content>, <content ID="encounterDiagnosisID2">Malocclusion Mesio-occlusion</content></td>
</tr>
</tbody> <!-- Some systems may include the CPT E&M code descriptions in the narrative -->
</table>
</text>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49" assigningAuthorityName="CCDA Encounter Activity" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.49" assigningAuthorityName="CCDA Encounter Activity" />
<id root="2.16.840.1.113883.3.140.1.1918489287.6.10.16" extension="449" assigningAuthorityName="Intergy Encounter ID" />
<id root="2.16.840.1.113883.3.140.1.1918489287.6.10.16.1" extension="271818" assigningAuthorityName="Intergy Encounter Number" />
<code code="AMB" displayName="ambulatory" codeSystem="2.16.840.1.113883.1.11.13955" codeSystemName="ActEncounterCode">
<originalText>
<reference value="#encounterTypeDescriptionID0"/><!-- This is the text the user saw and was the basis for the AMB coding -->
</originalText>
</code>
<text>
<reference value="#encounterDescriptionID0" />
</text>
<effectiveTime>
<low value="20170918093900-0400" />
<high value="20170918095100-0400" />
</effectiveTime>
<!-- Could include optional performer -->
<entryRelationship typeCode="COMP"> <!-- Encounter Diagnosis Act -->
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.80" assigningAuthorityName="CCDA Encounter Diagnosis" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.80" assigningAuthorityName="CCDA Encounter Diagnosis" />
<id root="2.16.840.1.113883.3.140.1.1918489287.6.10.7" extension="449" />
<code code="29308-4" displayName="Diagnosis" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
<entryRelationship typeCode="SUBJ" inversionInd="false">
<observation classCode="OBS" moodCode="EVN" negationInd="false">
<templateId root="2.16.840.1.113883.10.20.22.4.4" assigningAuthorityName="CCDA Problem Observation" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.4" assigningAuthorityName="CCDA Problem Observation" />
<id root="755efd22-a0d1-4504-9e6f-de4e173f91bc" />
<code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<translation code="75326-9" displayName="Problem" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
</code>
<statusCode code="completed" />
<effectiveTime>
<low value="20170918093900-0400" />
<high nullFlavor="NI"/> <!-- Better to omit high if problem is ongoing, but if you always include high use nullFlavor=NI -->
</effectiveTime>
<value code="235083001" displayName="Asymmetry of maxilla (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" xsi:type="CD">
<originalText>
<reference value="#encounterDiagnosisID0" />
</originalText>
<translation code="524.11" displayName="Jaw Asymmetry Maxillary" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD9CM" />
<translation code="M26.11" displayName="Jaw Asymmetry Maxillary" codeSystem="2.16.840.1.113883.6.3" codeSystemName="ICD10" />
<translation code="95980" displayName="Jaw Asymmetry Maxillary" codeSystem="2.16.840.1.113883.6.26" codeSystemName="MEDCIN" />
</value>
</observation>
</entryRelationship>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<observation classCode="OBS" moodCode="EVN" negationInd="false">
<templateId root="2.16.840.1.113883.10.20.22.4.4" assigningAuthorityName="CCDA Problem Observation" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.4" assigningAuthorityName="CCDA Problem Observation" />
<id root="c351f35e-ad79-4519-aae2-153526171926" />
<code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<translation code="75326-9" displayName="Problem" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
</code>
<statusCode code="completed" />
<effectiveTime>
<low value="20170918093900-0400" />
<high nullFlavor="NI"/> <!-- Better to omit high if problem is ongoing, but if you always include high use nullFlavor=NI -->
</effectiveTime>
<value code="23997001" displayName="Anomaly of dental arch (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" xsi:type="CD">
<originalText>
<reference value="#encounterDiagnosisID1" />
</originalText>
<translation code="524.20" displayName="Anomaly of Dental Arch" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD9CM" />
<translation code="312141" displayName="Anomaly of Dental Arch" codeSystem="2.16.840.1.113883.6.26" codeSystemName="MEDCIN" />
</value>
</observation>
</entryRelationship>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<observation classCode="OBS" moodCode="EVN" negationInd="false">
<templateId root="2.16.840.1.113883.10.20.22.4.4" assigningAuthorityName="CCDA Problem Observation" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.4" assigningAuthorityName="CCDA Problem Observation" />
<id root="1dd3d744-6108-4284-823a-138c2568e446" />
<code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<translation code="75326-9" displayName="Problem" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
</code>
<statusCode code="completed" />
<effectiveTime>
<low value="20170918093900-0400" />
<high nullFlavor="NI"/> <!-- Better to omit high if problem is ongoing, but if you always include high use nullFlavor=NI -->
</effectiveTime>
<value code="12264001" displayName="Mesio-occlusion of teeth (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" xsi:type="CD">
<originalText>
<reference value="#encounterDiagnosisID2" />
</originalText>
<translation code="524.23" displayName="Malocclusion Mesio-occlusion" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD9CM" />
<translation code="M26.213" displayName="Malocclusion Mesio-occlusion" codeSystem="2.16.840.1.113883.6.3" codeSystemName="ICD10" />
<translation code="219237" displayName="Malocclusion Mesio-occlusion" codeSystem="2.16.840.1.113883.6.26" codeSystemName="MEDCIN" />
</value>
</observation>
</entryRelationship>
</act>
</entryRelationship>
<entryRelationship typeCode="REFR" inversionInd="false">
<act classCode="ACT" moodCode="EVN">
<code code="99408" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12" displayName="Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes" />
</act>
</entryRelationship>
<entryRelationship typeCode="REFR" inversionInd="false">
<act classCode="ACT" moodCode="EVN">
<code code="99394" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12" displayName="Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent"/>
</act>
</entryRelationship>
<entryRelationship typeCode="REFR" inversionInd="false">
<act classCode="ACT" moodCode="EVN">
<code code="99213" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12" displayName="Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter."/>
</act>
</entryRelationship>
</encounter>
</entry>
</section>