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  1. FHIR Specification Feedback
  2. FHIR-40441

Allow null diagnosis values for Professional EOBs



    • Icon: Change Request Change Request
    • Resolution: Unresolved
    • Icon: Medium Medium


      The current EOB Professional Non-Clinical profile is too restrictive when it comes to Diagnosis codes. Working with a state Medicaid agency, there are several circumstances where Professional EOBs exist with no associated Diagnosis:


      1. Sensitive conditions and/or confidentiality. SAMHSA 42 CFR Part 2 is a rule that specifically provides additional Federal protections for individuals treated for substance abuse disorder. There are other sensitive diagnostic conditions where the data may simply be hidden or not populated except for very specific conditions.
      2. Maintenance Services. We have many claims for HCBS providers with a ‘developmental disability’ specialty. So these would be a home health agency-type provider, where they deliver personal care attendant services to recipients under a waiver program. Because of the nature of the services (personal care attendant/maintenance services/ADL services) and the fact that it is under a waiver, there may just not be a requirement to bill with a diagnosis code.

      There may be other circumstances where legitimate production data yields a Professional EOB lacking a Diagnosis code, but these are just some examples where the IG should consider adding flexibility.

      Similar to changes made to the value set bound to ExplanationOfBenefit.item.productOrService (where a Data Absent Reason was directly incorporated into the bound value set), I recommend directly incorporating a Data Absent Reason to the Diagnosis Codes value set (http://hl7.org/fhir/us/carin-bb/ValueSet-CDCICD910CMDiagnosisCodes.html), or potentially relaxing the terminology binding to be Extensible.




            Unassigned Unassigned
            Russell Ott Russell Ott
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