Specification - Extended

HL7 CDA® R2 IG: C-CDA Templates for Clinical Notes DSTU Release 2.1 - US Realm

Document Description

extended per extended per TSC tracker 12437, again with 14128 and jira.hl7.org/browse/TSC-38

Existing Wording

Value Set binding for Procedure Activity Procedure is highly problematic. Procedure Activity Procedure (V2) [procedure: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.14:2014-06-09 (open)] This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19207). The broad guidance/vocabulary binding creates a challenge for interoperability. Mappings between these code systems are not maintained as an available, consistent resource for all implementers. If maps did exist, they would need to be updated every time any one of these code systems was updated. This needs to be addressed.

Proposed Wording

Make the value set binding specific. We need to be clearer about when and where to use a billing code and when/where to a LOINC or SNOMED code. CPT, HCPCs and ICD codes are used for billing and right now there are not any good maps to support interoperability. We need to clarify what value sets should be used where and how to deal with any mappings that may be needed to translate across this space for interoperability.