Additional Information Specification 0003: Rehabilitation Services Attachment

Transcription

1 Additional Information Specification 0003: Rehabilitation Services Attachment (This specification replaces Additional Information Message 0003: Rehabilitation Services Attachment September 1, 2002) Release 2.1 Based on HL7 CDA Standard Release 1.0, with supporting LOINC Tables Copyright Health Level Seven. All Rights Reserved.

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3 Table of Contents 1 INTRODUCTION LOINC CODES AND STRUCTURE REVISION HISTORY PRIVACY CONCERNS IN EXAMPLES HL7 ATTACHMENT -CDA DOCUMENT VARIANTS REQUEST FOR INFORMATION VERSUS REQUEST FOR SERVICE LOINC CODES REHABILITATION SERVICES SUPPORTING DOCUMENTATION SCOPE MODIFICATION CODES SPECIAL CONSIDERATIONS FOR SENDING MEDICATIONS ATTACHMENT DATA COMPONENTS Alcohol-Substance Abuse Rehabilitation Attachment Cardiac Rehabilitation Attachment Medical Social Services Rehabilitation Attachment Occupational Therapy Rehabilitation Attachment Physical Therapy Rehabilitation Attachment Psychiatric Rehabilitation Attachment Respiratory Therapy Rehabilitation Attachment Skilled Nursing Rehabilitation Attachment Speech Therapy Rehabilitation Attachment REHABILITATION SERVICES ATTACHMENT VALUE TABLES ALCOHOL-SUBSTANCE ABUSE REHABILITATION SERVICE VALUE TABLE CARDIAC REHABILITATION SERVICE VALUE TABLE MEDICAL SOCIAL SERVICES REHABILITATION VALUE TABLE OCCUPATIONAL THERAPY REHABILITATION SERVICE VALUE TABLE PHYSICAL THERAPY REHABILITATION VALUE TABLE PSYCHIATRIC REHABILITATION SERVICE VALUE TABLE RESPIRATORY THERAPY REHABILITATION SERVICE VALUE TABLE SKILLED NURSING REHABILITATION SERVICE VALUE TABLE SPEECH THERAPY REHABILITATION SERVICE VALUE TABLE CODING EXAMPLES SCENARIO Coded Rehabilitation Plan, Human-Decision Variant Coded Rehabilitation Plan, Computer-Decision Variant RESPONSE CODE SETS HL70136: HL7 YES-NO INDICATOR HL70162: HL7 ROUTE OF MEDICINE ADMINISTRATION HL79002: HL7 REHABILITATION PLAN STATUS HL79003: HL7 REHABILITATION PLAN CONTINUE/DISCONTINUE INDICATOR HL79005: HL7 REHABILITATION PLAN PROGNOSIS HL79006: HL7 REHABILITATION SERVICE REMISSION STATUS HL79015: HL7 FREQUENCY BASE PERIOD I9C : ICD-9-CM ISO+: EXTENDED ISO UNITS CODES NDC: NATIONAL DRUG CODE NPI: NATIONAL PROVIDER IDENTIFIER PTX: HEALTH CARE PROVIDER TAXONOMY Page iii

4 Index of Tables and Figures Table 1.1 Relationship of LOINC Codes, X12N Transactions, and HL7 CDA Documents... 2 Table 2.1 s for a complete rehabilitation attachment data set... 4 Table Data Components for Alcohol-Substance Abuse Rehabilitation Attachment... 5 Table Data Components for Cardiac Rehabilitation Attachment... 7 Table Data Components for Medical Social Services Rehabilitation Attachment... 7 Table Data Components for Occupational Therapy Rehabilitation Attachment... 8 Table Data Components for Physical Therapy Rehabilitation Attachment... 9 Table Data Components for Psychiatric Rehabilitation Attachment Table Data Components for Respiratory Therapy Rehabilitation Attachment Table Data Components for Skilled Nursing Rehabilitation Attachment Table Data Components for Speech Therapy Rehabilitation Attachment Table 3.1 Alcohol-Substance Abuse Rehabilitation Service Table Table 3.2 Cardiac Rehabilitation Service Table Table 3.3 Medical Social Services Rehabilitation Table Table 3.4 Occupational Therapy Rehabilitation Service Table Table 3.5 Physical Therapy Rehabilitation Service Va lue Table Table 3.6 Psychiatric Rehabilitation Service Table Table 3.7 Respiratory Therapy Rehabilitation Service Table Table 3.8 Skilled Nursing Rehabilitation Service Table Table 3.9 Speech Therapy Rehabilitation Service Table Figure 4.1 Psychiatric Rehabilitation Plan Data Example Psychiatric Rehabilitation Plan, Human-Decision Variant Figure 1. Portion of Rendered Human-Decision Variant Example Psychiatric Rehabilitation Plan, Computer-Decision Variant Table 5.1 HL7 Yes-No Indicator Table Route of administration Table 5.3 HL7 Rehabilitation Plan Status Table 5.4 HL7 Rehabilitation Plan Continue/Discontinue Indicator Table 5.5 HL7 Rehabilitation Plan Prognosis Table 5.6 HL7 Rehabilitation Service Remission Status Table 5.7 HL7 Frequency Base Period Page iv

5 1 Introduction This publication provides the LOINC 1 code values specific to a rehabilitation services attachment for the following applications. Those codes that define the attachment or attachment components used in transactions such as those defined by the ASC X12N 277 (004050X150) Health Care Claim Request for Additional Information and the ASC X12N 275 (004050X151) Additional Information to Support a Health Care Claim or Encounter Implementation Guides which are products of the insurance subcommittee, X12N, of Accredited Standards Committee X12. 2,3 All of the codes may be used in HL7 Clinical Document Architecture (CDA) documents designed for inclusion in the BIN segment of the 275 transaction as described in the HL7 Additional Information Specification Implementation Guide 4 The format of this document and the methods used to arrive at its contents are prescribed in the HL7 Additional Information Specification Implementation Guide. Section 2 of this document defines the s used to request rehabilitation services attachments, and the s of each component in an attachment. Section 3 further describes each component of a specific rehabilitation services attachment, the cardinality of the components and their answer parts, and the description, data types, codes, and units of each answer part. Section 4 presents coding examples, with a narrative scenario, an XML example, and a display image of each example attachment using a popular browser. Section 5 further describes the code sets used in the response to each answer part of the attachment. Note: All s and descriptions are copyrighted by the Regenstrief Institute, with all rights reserved. See LOINC Codes and Structure s are used for several purposes: In the X12N 277 transaction set, s identify the attachment or attachment components being requested to support a claim or encounter. In the HL7 CDA document, s are used to identify the attachment, the attachment components, and their answer parts. This is returned in the X12N 275 transaction set. LOINC modifier codes may be used in the 277 transaction to further define the specificity of a request. 1 LOINC is a registered trademark of Regenstrief Institute and the LOINC Committee. The LOINC database and LOINC Users Guide are copyright Regenstrief Institute and the LOINC Committee and the LOINC database codes and names are available at no cost from Regenstrief Institute, 1050 Wishard Blvd., Indianapolis, IN LOINC@regenstrief.org 2 Information on this and other X12N/HIPAA-related implementation guides is available from the Washington Publishing Company, PMB 161, 5284 Randolph Rd., Rockville, MD Phone: or 3 Within this Health Level Seven document, references to the transaction defined by these X12N implementation guides will be abbreviated by calling them 275 and Health Level Seven, Inc Washtenaw Ave., Suite 227, Ann Arbor, MI ( Page 1

6 Table 1.1 Relationship of LOINC Codes, X12N Transactions, and HL7 CDA Documents. Purpose of Attachment LOINC Modifier Codes X12N 277 X12N 275 HL7 CDA Additional information to support a health care claim or encounter Request for additional information to support a health care claim Used in the STC segment to limit the scope or time frame of a request for information. e.g., Send information for up to 90 days before the related encounter Reiterated in the STC segment Provide controlled content for X12N 275 BIN segment Not used in the CDA document LOINC Attachment Identifier LOINC Attachment Component Used in the STC segment to request an attachment in its entirety, e.g., Send the rehab treatment plan Used in the STC segment to request a specific attachment component or part of a clinical report,.e.g., Send the rehab treatment plan author Reiterated in the STC segment Reiterated in the STC segment Used in the <document_type_cd> element of the header Used in the computerdecision CDA variant in the <caption_cd> element of a to identify the attachment component being provided, e.g., This is the author information LOINC Attachment Component Answer Part Not used in the 277 Not used in the 275 except within the CDA instance document in the BIN segment. Used in the computerdecision CDA variant in the <caption_cd> element of a, an <item> element within a <list> or a <td> element within a <table> to identify the answer part of an attachment component being provided, e.g., This is the name, identifier and taxonomy Page 2

7 1.2 Revision History Date Sep 30, 1998 Dec 2001 August 2003 December 2003 December 2003 Purpose Initial release as separate document. Revised title and date; reconciled HL7 ballot responses CDA Ballot Version 2.0 Publication Release 2.1 Ballot Release 2.1 Publication 1.3 Privacy Concerns in Examples The names of natural persons that appear in the examples of this book are intentionally fictional. Any resemblance to actual natural persons, living or deceased is purely coincidental. 1.4 HL7 Attachment-CDA Document Variants As described in the HL7 Additional Information Specification Implementation Guide, there are two variants of a CDA document when used as an attachment. The human-decision variant is used solely for information that will be rendered for a person to look at, in order to make a decision. HL7 provides a non-normative style sheet for this purpose. There are two further alternatives within the human-decision variant. non_xml body: The information can be sent with a CDA header structured in XML, along with a "non_xml body" that references scanned images of documents that contain the submitted information xml body: the information can be sent as free text in XML elements that organize the material into sections, paragraphs, tables and lists as described in the HL7 Additional Information Specification Implementation Guide. The computer-decision variant has the same content as the human-decision variant, but additional coded and structured information is included so that a computer could provide decision support based on the document. Attachments in the computer-decision variant can be rendered for human decisions using the same style sheet that HL7 provides for rendering documents formatted according to the human-decision variant. 1.5 Request for Information versus Request for Service This attachment specification for rehabilitation services defines a send-me-what-you-have attachment. It asks for a set of rehabilitation services attachment components gathered during the rehabilitation services care process. It is not asking for any additional data capture efforts. For example, if the request for data is to send the longest term of sobriety and this information was not captures at the time of care, it is not asking the provider to obtain additional information if they don t already have this information. In any attachment component answer part it may sometimes be impossible to send a required answer and necessary to send, instead, a reason why the information is not available. In the human decision variant the sender shall supplement the natural language explanation of why the information is not available with local markup. In the computer-decision variant the sender shall include local markup to describe the reason that the information is not available as described in the Data s section of the HL7 Additional Information Specification Implementation Page 3

8 2 LOINC Codes 2.1 Rehabilitation Services Supporting Documentation Table 2.1 defines the s used to request a complete attachment data set specific to a given rehabilitation treatment plan. The use of any of these codes in the 277 STC segment represents an explicit request for the complete set of data components relevant to the requested rehabilitation treatment plan. The provider shall return all data components for which data is available. The provider may choose to return images of pages that constitute the requested information by using the <non_xml> element of the CDA as described in the HL7 Additional Information Specification Implementation Guide. The set of data components for each rehabilitation service attachment, identified by individual s, is defined in Section 2.4. Table 2.1 s for a complete rehabilitation attachment data set Attachment Name Alcohol-substance abuse rehabilitation attachment Cardiac rehabilitation attachment Medical social services rehabilitation attachment Occupational therapy rehabilitation attachment Physical therapy rehabilitation attachment Psychiatric rehabilitation attachment Respiratory therapy rehabilitation attachment Skilled nursing rehabilitation attachment Speech therapy rehabilitation attachment 2.2 Scope Modification Codes The HL7 publication LOINC Modifier Codes (for use with ASC X12N Implementation Guides when Requesting Additional Information) provides code values for further defining the specificity of a request for additional information. Both time window and item selection modifier codes are defined. This publication is available from HL7, and is in the download package with the AIS documents. 2.3 Special Considerations for Sending Medications The s for rehabilitation plans include some that can be used to request or send medications used as part of a plan. The considerations for sending medications are de scribed in Section 2 of Additional Information Specification 0006: Medications Attachment. The sender shall use the instructions in that document for sending medications in rehabilitation plans. 2.4 Attachment Data Components Individual s are defined for each data component of the attachment specific to the disciplines listed in Table 2.1. These s are listed in sections to respectively. For example, the data components comprising the cardiac rehabilitation attachment (LOINC Page 4

9 ) appear in Table Each table is headed by the defining the complete attachment. The s in Table 2.1 represent requests for complete rehabilitation services attachments. However, the requester also has the option of focusing on a specific component of the attachment through the use of the s defined in the following tables. In this case the provider will respond with information, where available, specific to the requested data components. The attachment content of seven of the disciplines (cardiac rehabilitation, medical social services, occupational therapy, physical therapy, respiratory therapy, skilled nursing and speech therapy) is virtually identical. The data components differ only by the name of the discipline. Psychiatric and alcohol-substance abuse attachments include the same general content with the addition of several data components unique to those disciplines. The following tables show the specific data components and their s for each of the nine rehabilitation disciplines. These s may be used in ASC X12N 277 as defined in the associated Implementation Guide and will be mirrored in the corresponding ASC X12N 275 response. In addition, these s are used in the <caption_cd> element of the computerdecision variant of HL7 Additional Information Specification Implementation Guide. The questions that these s represent are the result of a significant industry outreach project and represent the complete set of rehabilitation services attachment components Alcohol-Substance Abuse Rehabilitation Attachment Table Data Components for Alcohol-Substance Abuse Rehabilitation Attachment LOINC Code Description ALCOHOL-SUBSTANCE ABUSE REHABILITATION ATTACHMENT ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, NEW/REVISED ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE ONSET OR EXACERBATION OF PRIMARY DIAGNOSIS ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, START DATE ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PRIMARY DIAGNOSIS ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, AUTHOR OF TREATMENT PLAN ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, VISIT FREQUENCY ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE RANGE (FROM/THROUGH) DESCRIBED BY PLAN ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, CONTINUATION STATUS ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE ATTENDING MD REFERRED PATIENT FOR TREATMENT ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE ATTENDING MD SIGNED ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE REHAB PROFESSIONAL SIGNED ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, SIGNATURE OF RESPONSIBLE ATTENDING MD ON FILE ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, SIGNATURE OF RESPONSIBLE REHAB PROFESSIONAL ON FILE ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, MEDICATION ADMINISTERED Page 5

10 LOINC Code Description ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PROGNOSIS FOR REHABILITATION ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, ESTIMATED DATE OF COMPLETION ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE OF LAST PLAN OF TREATMENT CERTIFICATION ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PAST MEDICAL HISTORY + LEVEL OF FUNCTION ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, INITIAL ASSESSMENT ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PLAN OF TREATMENT ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PROGRESS NOTE + ATTAINMENT OF GOALS ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, REASON TO CONTINUE ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, JUSTIFICATION ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, CHIEF COMPLAINT + REASON FOR REFERRAL + REASON FOR RELAPSE IF KNOWN ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, HISTORY OF PRESENT ALCOHOL/SUBSTANCE ABUSE ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, FOLLOWUP APPROACH ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, LEVEL OF PATIENT PARTICIPATION ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF NEXT PLANNED REHABILITATION TREATMENT ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, NEXT PLAN OF TREATMENT TEXT ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, ALCOHOL/SUBSTANCE ABUSE SYMPTOMS WITH PHYSIOLOGICAL DEPENDENCE INDICATOR ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, REHABILITATION PROBLEM REMISSION STATUS ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, LONGEST PERIOD OF SOBRIETY FOR ABUSED SUBSTANCE Page 6

11 2.4.2 Cardiac Rehabilitation Attachment Table Data Components for Cardiac Rehabilitation Attachment LOINC Code Description CARDIAC REHABILITATION ATTACHMENT CARDIAC REHABILITATION TREATMENT PLAN, NEW/REVISED CARDIAC REHABILITATION TREATMENT PLAN, DATE ONSET OR EXACERBATION OF PRIMARY DIAGNOSIS CARDIAC REHABILITATION TREATMENT PLAN, START DATE CARDIAC REHABILITATION TREATMENT PLAN, PRIMARY DIAGNOSIS CARDIAC REHABILITATION TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN CARDIAC REHABILITATION TREATMENT PLAN, AUTHOR OF TREATMENT PLAN CARDIAC REHABILITATION TREATMENT PLAN, VISIT FREQUENCY CARDIAC REHABILITATION TREATMENT PLAN, DATE RANGE (FROM/THROUGH) DESCRIBED BY PLAN CARDIAC REHABILITATION TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT CARDIAC REHABILITATION TREATMENT PLAN, CONTINUATION STATUS CARDIAC REHABILITATION TREATMENT PLAN, DATE ATTENDING MD REFERRED PATIENT FOR TREATMENT CARDIAC REHABILITATION TREATMENT PLAN, DATE ATTENDING MD SIGNED CARDIAC REHABILITATION TREATMENT PLAN, DATE CARDIAC REHABILITATION PROFESSIONAL SIGNED CARDIAC REHABILITATION TREATMENT PLAN, SIGNATURE OF RESPONSIBLE ATTENDING MD ON FILE CARDIAC REHABILITATION TREATM ENT PLAN, SIGNATURE OF RESPONSIBLE CARDIAC REHABILITATION PROFESSIONAL ON FILE CARDIAC REHABILITATION TREATMENT PLAN, MEDICATION ADMINISTERED CARDIAC REHABILITATION TREATMENT PLAN, PROGNOSIS FOR CARDIAC REHABILITATION CARDIAC REHABILITATION TREATMENT PLAN, ESTIMATED DATE OF COMPLETION CARDIAC REHABILITATION TREATMENT PLAN, DATE OF LAST PLAN OF TREATMENT CERTIFICATION CARDIAC REHABILITATION TREATMENT PLAN, PAST MEDICAL HISTORY + LEVEL OF FUNCTION CARDIAC REHABILITATION TREATMENT PLAN, INITIAL ASSESSMENT CARDIAC REHABILITATION TREATMENT PLAN, PLAN OF TREATMENT CARDIAC REHABILITATION TREATMENT PLAN, PROGRESS NOTE + ATTAINMENT OF GOALS CARDIAC REHABILITATION TREATMENT PLAN, REASON T O CONTINUE CARDIAC REHABILITATION TREATMENT PLAN, JUSTIFICATION Medical Social Services Rehabilitation Attachment Table Data Components for Medical Social Services Rehabilitation Attachment LOINC Code Description MEDICAL SOCIAL SERVICES REHABILITATION ATTACHMENT MEDICAL SOCIAL SERVICES TREATMENT PLAN, NEW/REVISED MEDICAL SOCIAL SERVICES TREATMENT PLAN, DATE ONSET OR EXACERBATION OF PRIMARY DIAGNOSIS MEDICAL SOCIAL SERVICES TREATMENT PLAN, START DATE MEDICAL SOCIAL SERVICES TREATMENT PLAN, PRIMARY DIAGNOSIS MEDICAL SOCIAL SERVICES TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN MEDICAL SOCIAL SERVICES TREATMENT PLAN, AUTHOR OF TREATMENT PLAN MEDICAL SOCIAL SERVICES TREATMENT PLAN, VISIT FREQUENCY MEDICAL SOCIAL SERVICES TREATMENT PLAN, DATE RANGE (FROM/THROUGH) DESCRIBED BY PLAN Page 7

12 LOINC Code Description MEDICAL SOCIAL SERVICES TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT MEDICAL SOCIAL SERVICES TREATMENT PLAN, CONTINUATION STATUS MEDICAL SOCIAL SERVICES TREATMENT PLAN, DATE ATTENDING MD REFERRED PATIENT FOR TREATMENT MEDICAL SOCIAL SERVICES TREATMENT PLAN, DATE ATTENDING MD SIGNED MEDICAL SOCIAL SERVICES TREATMENT PLAN, DATE MEDICAL SOCIAL SERVICES PROFESSIONAL SIGNED MEDICAL SOCIAL SERVICES TREATMENT PLAN, SIGNATURE OF RESPONSIBLE ATTENDING MD ON FILE MEDICAL SOCIAL SERVICES TREATMENT PLAN, SIGNATURE OF RESPONSIBLE MEDICAL SOCIAL SERVICES PROFESSIONAL ON FILE MEDICAL SOCIAL SERVICES TREATMENT PLAN, MEDICATION ADMINISTERED MEDICAL SOCIAL SERVICES TREATMENT PLAN, PROGNOSIS FOR MEDICAL SOCIAL SERVICES MEDICAL SOCIAL SERVICES TREATMENT PLAN, ESTIMATED DATE OF COMPLETION MEDICAL SOCIAL SERVICES TREATMENT PLAN, DATE OF LAST PLAN OF TREATMENT CERTIFICATION MEDICAL SOCIAL SERVICES TREATMENT PLAN, PAST MEDICAL HISTORY + LEVEL OF FUNCTION MEDICAL SOCIAL SERVICES TREATMENT PLAN, INITIAL ASSESSMENT MEDICAL SOCIAL SERVICES TREATMENT PLAN, PLAN OF TREATMENT MEDICAL SOCIAL SERVICES TREATMENT PLAN, PROGRESS NOTE + ATTAINMENT OF GOALS MEDICAL SOCIAL SERVICES TREATMENT PLAN, REASON TO CONTINUE MEDICAL SOCIAL SERVICES TREATMENT PLAN, JUSTIFICATION Occupational Therapy Rehabilitation Attachment Table Data Components for Occupational Therapy Rehabilitation Attachment LOINC Code Description OCCUPATIONAL THERAPY REHABILITATION ATTACHMENT OCCUPATIONAL THERAPY TREATMENT PLAN, NEW/REVISED OCCUPATIONAL THERAPY TREATMENT PLAN, DATE ONSET OR EXACERBATION OF PRIMARY DIAGNOSIS OCCUPATIONAL THERAPY TREATMENT PLAN, START DATE OCCUPATIONAL THERAPY TREATMENT PLAN, PRIMARY DIAGNOSIS OCCUPATIONAL THERAPY TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN OCCUPATIONAL THERAPY TREATMENT PLAN, AUTHOR OF TREATMENT PLAN OCCUPATIONAL THERAPY TREATMENT PLAN, VISIT FREQUENCY OCCUPATIONAL THERAPY TREATMENT PLAN, DATE RANGE (FROM/THROUGH) DESCRIBED BY PLAN OCCUPATIONAL THERAPY TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT OCCUPATIONAL THERAPY TREATMENT PLAN, CONTINUATION STATUS OCCUPATIONAL THERAPY TREATMENT PLAN, DATE ATTENDING MD REFERRED PATIENT FOR TREATMENT OCCUPATIONAL THERAPY TREATMENT PLAN, DATE ATTENDING MD SIGNED OCCUPATIONAL THERAPY TREATMENT PLAN, DATE OCCUPATIONAL THERAPY PROFESSIONAL SIGNED OCCUPATIONAL THERAPY TREATMENT PLAN, SIGNATURE OF RESPONSIBLE ATTENDING MD ON FILE OCCUPATIONAL THERAPY TREATMENT PLAN, SIGNATURE OF RESPONSIBLE OCCUPATIONAL THERAPY PROFESSIONAL ON FILE OCCUPATIONAL THERAPY TREATMENT PLAN, MEDICATION ADMINISTERED OCCUPATIONAL THERAPY TREATMENT PLAN, PROGNOSIS FOR OCCUPATIONAL THERAPY OCCUPATIONAL THERAPY TREATMENT PLAN, ESTIMATED DATE OF COMPLETION Page 8

13 LOINC Code Description OCCUPATIONAL THERAPY TREATMENT PLAN, DATE OF LAST PLAN OF TREATMENT CERTIFICATION OCCUPATIONAL THERAPY TREATMENT PLAN, PAST MEDICAL HISTORY + LEVEL OF FUNCTION OCCUPATIONAL THERAPY TREATMENT PLAN, INITIAL ASSESSMENT OCCUPATIONAL THERAPY TREATMENT PLAN, PLAN OF TREATMENT OCCUPATIONAL THERAPY TREATMENT PLAN, PROGRESS NOTE + ATTAINMENT OF GOALS OCCUPATIONAL THERAPY TREATMENT PLAN, REASON TO CONTINUE OCCUPATIONAL THERAPY TREATMENT PLAN, JUSTIFICATION Physical Therapy Rehabilitation Attachment Table Data Components for Physical Therapy Rehabilitation Attachment LOINC Code Description PHYSICAL THERAPY REHABILITATION ATTACHMENT PHYSICAL THERAPY TREATMENT PLAN, NEW/REVISED PHYSICAL THERAPY TREATMENT PLAN, DATE ONSET OR EXACERBATION OF PRIMARY DIAGNOSIS PHYSICAL THERAPY TREATMENT PLAN, START DATE PHYSICAL THERAPY TREATMENT PLAN, PRIMARY DIAGNOSIS PHYSICAL THERAPY TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN PHYSICAL THERAPY TREATMENT PLAN, AUTHOR OF TREATMENT PLAN PHYSICAL THERAPY TREATMENT PLAN, VISIT FREQUENCY PHYSICAL THERAPY TREATMENT PLAN, DATE RANGE (FROM/THROUGH) DESCRIBED BY PLAN PHYSICAL THERAPY TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT PHYSICAL THERAPY TREATMENT PLAN, CONTINUATION STATUS PHYSICAL THERAPY TREATMENT PLAN, DATE ATTENDING MD REFERRED PATIENT FOR TREATMENT PHYSICAL THERAPY TREATMENT PLAN, DATE ATTENDING MD SIGNED PHYSICAL THERAPY TREATMENT PLAN, DATE PHYSICAL THERAPY PROFESSIONAL SIGNED PHYSICAL THERAPY TREATMENT PLAN, SIGNATURE OF RESPONSIBLE ATTENDING MD ON FILE PHYSICAL THERAPY TREATMENT PLAN, SIGNATURE OF RESPONSIBLE PHYSICAL THERAPY PROFESSIONAL ON FILE PHYSICAL THERAPY TREATMENT PLAN, MEDICATION ADMINISTERED PHYSICAL THERAPY TREATMENT PLAN, PROGNOSIS FOR PHYSICAL THERAPY PHYSICAL THERAPY TREATMENT PLAN, ESTIMATED DATE OF COMPLETION PHYSICAL THERAPY TREATMENT PLAN, DATE OF LAST PLAN OF TREATMENT CERTIFICATION PHYSICAL THERAPY TREATMENT PLAN, PAST MEDICAL HISTORY + LEVEL OF FUNCTION PHYSICAL THERAPY TREATMENT PLAN, INITIAL ASSESSMENT PHYSICAL THERAPY TREATMENT PLAN, PLAN OF TREATMENT PHYSICAL THERAPY TREATMENT PLAN, PROGRESS NOTE + ATTAINMENT OF GOALS PHYSICAL THERAPY TREATMENT PLAN, REASON TO CONTINUE PHYSICAL THERAPY TREATMENT PLAN, JUSTIFICATION Page 9

14 2.4.6 Psychiatric Rehabilitation Attachment Table Data Components for Psychiatric Rehabilitation Attachment LOINC Code Description PSYCHIATRIC REHABILITATION ATTACHMENT PSYCHIATRIC REHABILITATION TREATMENT PLAN, NEW/REVISED PSYCHIATRIC REHABILITATION TREATMENT PLAN, DATE ONSET OR EXACERBATION OF PRIMARY DIAGNOSIS PSYCHIATRIC REHABILITATION TREATMENT PLAN, START DATE PSYCHIATRIC REHABILITATION TREATMENT PLAN, PRIMARY DIAGNOSIS PSYCHIATRIC REHABILITATION TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN PSYCHIATRIC REHABILITATION TREATMENT PLAN, AUTHOR OF TREATMENT PLAN PSYCHIATRIC REHABILITATION TREATMENT PLAN, VISIT FREQUENCY PSYCHIATRIC REHABILITATION TREATMENT PLAN, DATE RANGE (FROM/THROUGH) DESCRIBED BY PLAN PSYCHIATRIC REHABILITATION TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT PSYCHIATRIC REHABILITATION TREATMENT PLAN, CONTINUATION STATUS PSYCHIATRIC REHABILITATION TREATMENT PLAN, DATE ATTENDING MD REFERRED PATIENT FOR TREATMENT PSYCHIATRIC REHABILITATION TREATMENT PLAN, DATE ATTENDING MD SIGNED PSYCHIATRIC REHABILITATION TREATMENT PLAN, DATE REHAB PROFESSIONAL SIGNED PSYCHIATRIC REHABILITATION TREATMENT PLAN, SIGNATURE OF RESPONSIBLE ATTENDING MD ON FILE PSYCHIATRIC REHABILITATION TREATMENT PLAN, SIGNATURE OF RESPONSIBLE REHAB PROFESSIONAL ON FILE PSYCHIATRIC REHABILITATION TREATMENT PLAN, MEDICATION ADMINISTERED PSYCHIATRIC REHABILITATION TREATMENT PLAN, PROGNOSIS FOR REHABILITATION PSYCHIATRIC REHABILITATION TREATMENT PLAN, ESTIMATED DATE OF COMPLETION PSYCHIATRIC REHABILITATION TREATMENT PLAN, DATE OF LAST PLAN OF TREATMENT CERTIFICATION PSYCHIATRIC REHABILITATION TREATMENT PLAN, PAST MEDICAL HISTORY + LEVEL OF FUNCTION PSYCHIATRIC REHABILITATION TREATMENT PLAN, INITIAL ASSESSMENT PSYCHIATRIC REHABILITATION TREATMENT PLAN, PLAN OF TREATMENT PSYCHIATRIC REHABILITATION TREATMENT PLAN, PROGRESS NOTE + ATTAINMENT OF GOALS PSYCHIATRIC REHABILITATION TREATMENT PLAN, REASON TO CONTINUE PSYCHIATRIC REHABILITATION TREATMENT PLAN, JUSTIFICATION PSYCHIATRIC REHABILITATION TREATMENT PLAN, PSYCHIATRIC SYMPTOMS Respiratory Therapy Rehabilitation Attachment Table Data Components for Respiratory Therapy Rehabilitation Attachment LOINC Code Description RESPIRATORY THERAPY REHABILITATION ATTACHMENT RESPIRATORY THERAPY TREATMENT PLAN, NEW/REVISED RESPIRATORY THERAPY TREATMENT PLAN, DATE ONSET OR EXACERBATION OF PRIMARY DIAGNOSIS RESPIRATORY THERAPY TREATMENT PLAN, START DATE Page 10

15 LOINC Code Description RESPIRATORY THERAPY TREATMENT PLAN, PRIMARY DIAGNOSIS RESPIRATORY THERAPY TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN RESPIRATORY THERAPY TREATMENT PLAN, AUTHOR OF TREATMENT PLAN RESPIRATORY THERAPY TREATMENT PLAN, VISIT FREQUENCY RESPIRATORY THERAPY TREATMENT PLAN, DATE RANGE (FROM/THROUGH) DESCRIBED BY PLAN RESPIRATORY THERAPY TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT RESPIRATORY THERAPY TREATMENT PLAN, CONTINUATION STATUS RESPIRATORY THERAPY TREATMENT PLAN, DATE ATTENDING MD REFERRED PATIENT FOR RESPIRATORY THERAPY TREATMENT PLAN, DATE ATTENDING MD SIGNED RESPIRATORY THERAPY TREATMENT PLAN, DATE RESPIRATORY THERAPY PROFESSIONAL SIGNED RESPIRATORY THERAPY TREATMENT PLAN, SIGNATURE OF RESPONSIBLE ATTENDING MD ON FILE RESPIRATORY THERAPY TREATMENT PLAN, SIGNATURE OF RESPONSIBLE RESPIRATORY THERAPY PROFESSIONAL ON FILE RESPIRATORY THERAPY TREATMENT PLAN, MEDICATION ADMINISTERED RESPIRATORY THERAPY TREATMENT PLAN, PROGNOSIS FOR RESPIRATORY THERAPY RESPIRATORY THERAPY TREATMENT PLAN, ESTIMATED DATE OF COMPLETION RESPIRATORY THERAPY TREATMENT PLAN, DATE OF LAST PLAN OF TREATMENT CERTIFICATION RESPIRATORY THERAPY TREATMENT PLAN, PAST MEDICAL HISTORY + LEVEL OF FUNCTION RESPIRATORY THERAPY TREATMENT PLAN, INITIAL ASSESSMENT RESPIRATORY THERAPY TREATMENT PLAN, PLAN OF TREATMENT RESPIRATORY THERAPY TREATMENT PLAN, PROGRESS NOTE + ATTAINMENT OF GOALS RESPIRATORY THERAPY TREATMENT PLAN, REASON TO CONTINUE RESPIRATORY THERAPY TREATMENT PLAN, JUSTIFICATION Skilled Nursing Rehabilitation Attachment Table Data Components for Skilled Nursing Rehabilitation Attachment LOINC Code Description SKILLED NURSING REHABILITATION ATTACHMENT SKILLED NURSING TREATMENT PLAN, NEW/REVISED SKILLED NURSING TREATMENT PLAN, DATE ONSET OR EXACERBATION OF PRIMARY DIAGNOSIS SKILLED NURSING TREATMENT PLAN, START DATE SKILLED NURSING TREATMENT PLAN, PRIMARY DIAGNOSIS SKILLED NURSING TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN SKILLED NURSING TREATMENT PLAN, AUTHOR OF TREATMENT PLAN SKILLED NURSING TREATMENT PLAN, VISIT FREQUENCY SKILLED NURSING TREATMENT PLAN, DATE RANGE (FROM/THROUGH) DESCRIBED BY PLAN SKILLED NURSING TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT SKILLED NURSING TREATMENT PLAN, CONTINUATION STATUS SKILLED NURSING TREATMENT PLAN, DATE ATTENDING MD REFERRED PATIENT FOR TREATMENT SKILLED NURSING TREATMENT PLAN, DATE ATTENDING MD SIGNED SKILLED NURSING TREATMENT PLAN, DATE SKILLED NURSING PROFESSIONAL SIGNED SKILLED NURSING TREATMENT PLAN, SIGNATURE OF RESPONSIBLE ATTENDING MD ON FILE Page 11

16 LOINC Code Description SKILLED NURSING TREATMENT PLAN, SIGNATURE OF RESPONSIBLE SKILLED NURSING PROFESSIONAL ON FILE SKILLED NURSING TREATMENT PLAN, MEDICATION ADMINISTERED SKILLED NURSING TREATMENT PLAN, PROGNOSIS FOR SKILLED NURSING SKILLED NURSING TREATMENT PLAN, ESTIMATED DATE OF COMPLETION SKILLED NURSING TREATMENT PLAN, DATE OF LAST PLAN OF TREATMENT CERTIFICATION SKILLED NURSING TREATMENT PLAN, PAST MEDICAL HISTORY + LEVEL OF FUNCTION SKILLED NURSING TREATMENT PLAN, INITIAL ASSESSMENT SKILLED NURSING TREATMENT PLAN, PLAN OF TREATMENT SKILLED NURSING TREATMENT PLAN, PROGRESS NOTE + ATTAINMENT OF GOALS SKILLED NURSING TREATMENT PLAN, REASON TO CONTINUE SKILLED NURSING TREATMENT PLAN, JUSTIFICATION Speech Therapy Rehabilitation Attachment Table Data Components for Speech Therapy Rehabilitation Attachment LOINC Code Description SPEECH THERAPY REHABILITATION ATTACHMENT SPEECH THERAPY TREATMENT PLAN, NEW/REVISED SPEECH THERAPY TREATMENT PLAN, DATE ONSET OR EXACERBATION OF PRIMARY DIAGNOSIS SPEECH THERAPY TREATMENT PLAN, START DATE SPEECH THERAPY TREATMENT PLAN, PRIMARY DIAGNOSIS SPEECH THERAPY TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN SPEECH THERAPY TREATMENT PLAN, AUTHOR OF TREATMENT PLAN SPEECH THERAPY TREATMENT PLAN, VISIT FREQUENCY SPEECH THERAPY TREATMENT PLAN, DATE RANGE (FROM/THROUGH) DESCRIBED BY PLAN SPEECH THERAPY TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT SPEECH THERAPY TREATMENT PLAN, CONTINUATION STATUS SPEECH THERAPY TREATMENT PLAN, DATE ATTENDING MD REFERRED PATIENT FOR TREATMENT SPEECH THERAPY TREATMEN T PLAN, DATE ATTENDING MD SIGNED SPEECH THERAPY TREATMENT PLAN, DATE SPEECH THERAPY PROFESSIONAL SIGNED SPEECH THERAPY TREATMENT PLAN, SIGNATURE OF RESPONSIBLE ATTENDING MD ON FILE SPEECH THERAPY TREATMENT PLAN, SIGNATURE OF RESPONSIBLE SPEECH THERAPY PROFESSIONAL ON FILE SPEECH THERAPY TREATMENT PLAN, MEDICATION ADMINISTERED SPEECH THERAPY TREATMENT PLAN, PROGNOSIS FOR THERAPY SPEECH THERAPY TREATMENT PLAN, ESTIMATED DATE OF COMPLETION SPEECH THERAPY TREATMENT PLAN, DATE OF LAST PLAN OF TREATMENT CERTIFICATION SPEECH THERAPY TREATMENT PLAN, PAST MEDICAL HISTORY + LEVEL OF FUNCTION SPEECH THERAPY TREATMENT PLAN, INITIAL ASSESSMENT SPEECH THERAPY TREATMENT PLAN, PLAN OF TREATMENT SPEECH THERAPY TREATMENT PLAN, PROGRESS NOTE + ATTAINMENT OF GOALS SPEECH THERAPY TREATMENT PLAN, REASON TO CONTINUE SPEECH THERAPY TREATMENT PLAN, JUSTIFICATION Page 12

17 3 Rehabilitation Services Attachment Tables Each of the tables in this section further describes the LOINC components listed in the above corresponding table, along with the expected answer part(s) for each question, including the data type, cardinality, and codes/units for each answer. The minimum attachment data set equates to the required components; those identified in the value table, below, with cardinality (Card) of {} (component is required and has one and only one occurrence) or {1,n} (component is required and has one or more occurrences). Those data components with a cardinality of {} (if available has one and only one occurrence) or {0,n} (if available may have one or more occurrences) shall be sent if available. 3.1 Alcohol-Substance Abuse Rehabilitation Service Table Table 3.1 Alcohol-Substance Abuse Rehabilitation Service Table ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, NEW/REVISED original 701 updated See section 5 for the list of valid codes. Data ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE ONSET OR EXACERBATION OF PRIMARY DIAGNOSIS DT ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, START DATE DT Card CE HL ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PRIMARY DIAGNOSIS ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PRIMARY DIAGNOSIS (IDENTIFIER) ICD-9CM code ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN (IDENTIFIER) ICD-9CM code. CE I9C CE I9C Page 13

18 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, AUTHOR OF TREATMENT PLAN (COMPOSITE) ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, AUTHOR NAME ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, AUTHOR IDENTIFIER Unique identifier for the professional who established the treatment plan. At some point use of the National Provider Identifier (NPI) will be mandated, until such time other identifiers such as UPIN or state license number are allowed. Note: S attribute will indicate the authority assigning the identifier; for example, NPI, UPIN, or XX, where XX is the two-letter US Postal Service abbreviation for the state of the licensing authority ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, AUTHOR PROFESSION As described by the Health Care Provider Taxonomy. Data Card PN CX See note at left. CE PTX ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, VISIT FREQUENCY TQ ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE RANGE (FROM/THROUGH) DESCRIBED BY PLAN (COMPOSITE) ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PLAN START DATE ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PLAN END DATE ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT (COMPOSITE) ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, STA RT DATE OF HOSPITALIZATION LEADING TO TREATMENT ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, END DATE OF HOSPITALIZATION LEADING TO TREATMENT DT DT DT DT Page 14

19 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, CONTINUATION STATUS C continue D discontinue Data Card CE HL ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT, DATE ATTENDING MD REFERRED PATIENT FOR TREATMENT DT ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE ATTENDING MD SIGNED DT ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE REHAB PROFESSIONAL SIGNED DT ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, SIGNATURE OF RESPONSIB LE ATTENDING MD ON FILE N No CE HL70136 Y Yes ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, SIGNATURE OF RESPONSIBLE REHAB PROFESSIONAL ON FILE N No Y Yes CE HL70136 Page 15

20 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, MEDICATION ADMINISTERED (COMPOSITE) Data Card 0,n Repeat the components as needed to report all medications administered as past of the rehabilitation treatment plan within the dates of service of the associated claim or for the period defined by the modifier codes. For additional details, see CDAR1AIS0006R021 Additional Information Specification 0006: Medications Attachment ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, MEDICATION NAME + IDENTIFIER NDC number and text preferred or just text. To affirmatively document that none were administered use the "No Information" data type ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, MEDICATION DOSE Supplement verbal information in the <content> element when units are complex or determined as unit per time ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, MEDICATION TIMING + QUANTITY ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, MEDICATION ROUTE See section 5 for the list of valid codes ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PROGNOSIS FOR REHABILITATION Poor 2 Guarded 3 Fair 4 Good 5 Excellent CE See note at left NDC (preferred) NM iso+ TQ CE HL70162 CE HL ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, ESTIMATED DATE OF COMPLETION DT ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE OF LAST PLAN OF TREATMENT CERTIFICATION DT Page 16

21 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PAST MEDICAL HISTORY + LEVEL OF FUNCTION (NARRATIVE) Data TX Card ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, INITIAL ASSESSMENT (NARRATIVE) TX ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PLAN OF TREATMENT (NARRATIVE) TX ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PROGRESS NOTE + ATTAINMENT OF GOALS (NARRATIVE) TX ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, REASON TO CONTINUE (NARRATIVE) TX ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, JUSTIFICATION (NARRATIVE) TX ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, CHIEF COMPLAINT+REASON FOR REFERRAL+REASON FOR RELAPSE IF KNOWN (NARRATIVE) TX ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, HISTORY OF PRESENT ALCOHOL/SUBSTANCE ABUSE (NARRATIVE) TX Page 17

22 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, FOLLOWUP APPROACH (COMPOSITE) ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, AGENCY THAT WILL FOLLOW UP Provider may respond with agency or person. If both are sent, the person should be affiliated with the agency ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PERSON THAT WILL FOLLOW UP Provider may responds with agency or person. If both sent, the person should be affiliated with the agency ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, METHODOLOGY FOR FOLLOW UP ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, FREQUENCY OF ASSESSMENTS FOR FOLLOW UP Data Card ST PN TX TQ ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, LEVEL OF PATIENT PARTICIPATION ST ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF NEXT PLANNED TREATMENT (COMPOSITE) ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, NEXT PLANNED TREATMENT START DATE ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, NEXT PLANNED TREATMENT END DATE DT DT ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, NEXT PLAN OF TREATMENT TEXT (NARRATIVE) TX ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, ALCOHOL/SUBSTANCE ABUSE SYMPTOMS WITH PHYSIOLOGICAL DEPENDENCE INDICATOR N No Y Yes CE HL70136 Page 18

23 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, REHABILITATION PROBLEM REMISSION STATUS Early Full Remission 2 Early Partial Remission 3 Sustained Full Remission 4 Sustained Partial Remission ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, LONGEST PERIOD OF SOBRIETY FOR ABUSED SUBSTANCE (COMPOSITE) ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, ABUSED SUBSTANCE ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, LONGEST PERIOD OF SOBRIETY Include units for the period of sobriety: days, months, or weeks. Data Card CE HL ,n ST NM iso+ 3.2 Cardiac Rehabilitation Service Table Table 3.2 Cardiac Rehabilitation Service Table CARDIAC REHABILITATION TREATMENT PLAN, NEW/REVISED original 701 updated Data Card CE HL CARDIAC REHABILITATION TREATMENT PLAN, DATE ONSET OR EXACERBATION OF PRIMARY DIAGNOSIS DT CARDIAC REHABILITATION TREATMENT PLAN, START DATE DT CARDIAC REHABILITATION TREATMENT PLAN, PRIMARY DIAGNOSIS CARDIAC REHABILITATION TREATMENT PLAN, PRIMARY DIAGNOSIS (IDENTIFIER) ICD-9CM code. CE I9C CARDIAC REHABILITATION TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN CARDIAC REHABILITATION TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN (IDENTIFIER) ICD-9CM code. CE I9C Page 19

24 CARDIAC REHABILITATION TREATMENT PLAN, AUTHOR OF TREATMENT PLAN (COMPOSITE) CARDIAC REHABILITATION TREATMENT PLAN, AUTHOR NAME CARDIAC REHABILITATION TREATMENT PLAN, AUTHOR IDENTIFIER Unique identifier for the professional who established the treatment plan. At some point use of the National Provider Identifier (NPI) will be mandated, until such time other identifiers such as UPIN or state license number are allowed. Note: S attribute will indicate the authority assigning the identifier; for example, NPI, UPIN, or XX, where XX is the two-letter US Postal Service abbreviation for the state of the licensing authority CARDIAC REHABILITATION TREATMENT PLAN, AUTHOR PROFESSION As described by the Health Care Provider Taxonomy. Data Card PN CX See note at left CE PTX CARDIAC REHABILITATION TREATMENT PLAN, VISIT FREQUENCY TQ CARDIAC REHABILITATION TREATMENT PLAN, DATE RANGE (FROM/THROUGH) DESCRIBED BY PLAN (COMPOSITE) CARDIAC REHABILITATION TREATMENT PLAN, PLAN START DATE CARDIAC REHABILITATION TREATMENT PLAN, PLAN END DATE CARDIAC REHABILITATION TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT (COMPOSITE) CARDIAC REHABILITATION TREATMENT PLAN, START DATE OF HOSPITALIZATION LEADING TO TREATMENT CARDIAC REHABILITATION TREATMENT PLAN, END DATE OF HOSPITALIZATION LEADING TO TREATMENT CARDIAC REHABILITATION TREATMENT PLAN, CONTINUATION STATUS C continue D discontinue DT DT DT DT CE HL CARDIAC REHABILITATION TREATMENT PLAN, DATE ATTENDING MD REFERRED PATIENT FOR TREATMENT DT CARDIAC REHABILITATION TREATMENT PLAN, DATE ATTENDING MD SIGNED DT CARDIAC REHABILITATION TREATMENT PLAN, DATE CARDIAC REHABILITATION PROFESSIONAL SIGNED DT Page 20

25 CARDIAC REHABILITATION TREATMENT PLAN, SIGNATURE OF RESPONSIBLE ATTENDING MD ON FILE N No Y Yes CARDIAC REHABILITATION TREATMENT PLAN, SIGNATURE OF RESPONSIBLE CARDIAC REHABILITATION PROFESSIONAL ON FILE N No Y Yes CARDIAC REHABILITATION TREATMENT PLAN, MEDICATION ADMINISTERED (COMPOSITE) Data Card CE HL70136 CE HL ,n Repeat the components as needed to report all medications administered as past of the rehabilitation treatment plan within the dates of service of the associated claim or for the period defined by the modifier codes. For additional details, see CDAR1AIS0006R021 Additional Information Specification 0006: Medications Attachment CARDIAC REHABILITATION TREATMENT PLAN, MEDICATION NAME + IDENTIFIER NDC number and text preferred or just text. If none administered leave the attachment component out. To affirmatively document that none were administered use the "No Information" data type CARDIAC REHABILITATION TREATMENT PLAN, MEDICATION DOSE Supplement verbal information in the <content> element when units are complex or determined as unit per time CARDIAC REHABILITATION TREATMENT PLAN, MEDICATION TIMING + QUANTITY CARDIAC REHABILITATION TREATMENT PLAN, MEDICATION ROUTE See Section 5 for the list of valid codes CARDIAC REHABILITATION TREATMENT PLAN, PROGNOSIS FOR CARDIAC REHABILITATION Poor 2 Guarded 3 Fair 4 Good 5 Excellent CE See note at left. NDC (preferred) NM iso+ TQ CE HL70162 CE HL CARDIAC REHABILITATION TREATMENT PLAN, ESTIMATED DATE OF COMPLETION DT CARDIAC REHABILITATION TREATMENT PLAN, DATE OF LAST PLAN OF TREATMENT CERTIFICATION DT CARDIAC REHABILITATION TREATMENT PLAN, PAST MEDICAL HISTORY+LEVEL OF FUNCTION (NARRATIVE) TX Page 21

26 Data Card CARDIAC REHABILITATION TREATMENT PLAN, INITIAL ASSESSMENT (NARRATIVE) TX CARDIAC REHABILITATION TREATMENT PLAN, PLAN OF TREATMENT (NARRATIVE) TX CARDIAC REHABILITATION TREATMENT, PROGRESS NOTE+ATTAINMENT OF GOALS (NARRATIVE) TX CARDIAC REHABILITATION TREATMENT PLAN, REASON TO CONTINUE (NARRATIVE) TX CARDIAC REHABILITATION TREATMENT PLAN, JUSTIFICATION (NARRATIVE) TX 3.3 Medical Social Services Rehabilitation Table Table 3.3 Medical Social Services Rehabilitation Table MEDICAL SOCIAL SERVICES TREATMENT PLAN, NEW/REVISED original 701 updated Data Card CE HL MEDICAL SOCIAL SERVICES TREATMENT PLAN, DATE ONSET OR EXACERBATION OF PRIMARY DIAGNOSIS DT MEDICAL SOCIAL SERVICES TREATMENT PLAN, START DATE DT MEDICAL SOCIAL SERVICES TREATMENT PLAN, PRIMARY DIAGNOSIS MEDICAL SOCIAL SERVICES TREATMENT PLAN, PRIMARY DIAGNOSIS (IDENTIFIER) ICD-9CM code. CE I9C MEDICAL SOCIAL SERVICES TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN MEDICAL SOCIAL SERVICES TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN (IDENTIFIER) ICD-9CM code. CE I9C Page 22