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  1. CDA Specification Feedback
  2. CDA-20486

Allow ICD-10-PCS Operative Note serviceEvent/code and improve modelling

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    • Icon: Change Request Change Request
    • Resolution: Persuasive with Modification
    • Icon: Medium Medium
    • C-CDA Templates Clinical Notes (CDA)
    • 2.1.0.6 [deprecated]
    • Structured Documents
    • Templates [deprecated]
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      Update as suggested with minor modifications:

       

      Add the following new constraint:

      1. This serviceEvent MAY contain zero or one [0..1] code (CONF:XXXX).

       

      Update existing constraint as follows (adding ICD-10-PCS) and move it to be a child of the above new constraint:

        1. This code, if present, SHALL be selected from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).
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      Update as suggested with minor modifications:   Add the following new constraint: This serviceEvent MAY contain zero or one  [0..1]  code (CONF:XXXX).   Update existing constraint as follows (adding ICD-10-PCS) and move it to be a child of the above new constraint: This code, if present, SHALL be selected from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC  (CONF:1198-8487).
    • Russell Ott / Sean McIlvenna : 8-0-1
    • Correction
    • Compatible, substantive
    • 2.1.0.7 [deprecated]

    Description

      Currently the Operative Note document template has the following primitive constraint for documentationOf/serviceEvent/code, and no modelled constraint for the serviceEvent/code element:

      The value of serviceEvent/code SHALL be from ICD9 CM Procedures (CodeSystem 2.16.840.1.113883.6.104), CPT-4 (CodeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (CodeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 DYNAMIC (CONF:1198-8487).

       

      In accordance with similar updates to Procedure Note and Procedure Activity Act/Observation/Procedure templates, we should add a "parent" constraint for the serviceEvent/code element, and update the existing conformance statement to be as follows:

      1. This serviceEvent MAY contain zero or one [0..1] code (CONF:XXXX).
        1. The value of serviceEvent/code SHALL be selected from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).

       

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            Russell Ott Russell Ott
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              Updated:
              Resolved: