I’m implementing a FHIR transaction that represents the data from form CMS 1500, used in the US as a standard medical insurance claim form. I started working from the very useful mapping spreadsheet I found at http://wiki.hl7.org/index.php?title=File:CMS1500-FHIR.xlsx, which was contributed by @pknapp. After creating a representative FHIR object, I found a couple of data items that I believe should be mapped differently. I’m starting this thread as a basis for discussion.
Here are the two items I mapped differently:
- Box 24i (ID. QUAL) This box is not for the provider’s qualification. The official instructions for CMS-1500 state, “Enter the ID qualifier 1C in the shaded portion.” Elsewhere, the instructions say “Legacy Qualifier Rendering Provider (Leave Blank)”
- Service Facility Location (Box 32) I think this should refer to Claim.facility, which refers to a Location, instead of Claim.organization. An organization might have multiple service locations, and CMS-1500 wants to know which facility within the organization performed the service. Box 32a, Service Provider NPI, should refer to the organization, which has only one NPI to cover all its locations.
There are several other items that I wasn’t clear about. Below is the JSON representation that seems correct to me. Please let me know if I missed anything!
{
"resourceType": "Claim",
"id": "claim1",
"identifier": [
{
"value": "claim number goes here"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-claimtype",
"code": "professional",
"display": "Professional"
}
]
},
"use": "complete",
"facility": {
"reference": "Location/ormc-er"
},
"careTeam": [
{
"sequence": 1,
"provider": {
"reference": "Practitioner/provider1"
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "primaryInsurance"
},
"preAuthRef": [
"code from CMS-1500 Box 23"
]
}
],
"patient": {
"reference": "Patient/1"
},
"information": [
{
"sequence": 1,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/claiminformationcategory",
"code": "onset"
}
]
},
"timingDate": "2017-06-24"
},
{
"sequence": 2,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/claiminformationcategory",
"code": "related"
}
]
},
"timingDate": "2015-12-01"
},
{
"sequence": 3,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/claiminformationcategory",
"code": "info"
}
]
},
"code": {
"coding": [
{
"system": "http://hl7.org/fhir/payment-type",
"code": "payment"
}
]
},
"valueQuantity": {
"value": 25.00,
"code": "USD",
"system": "urn:iso:std:iso:4217"
}
},
{
"sequence": 4,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/claiminformationcategory",
"code": "info"
}
]
},
"code": {
"coding": [
{
"system": "http://hl7.org/fhir/v3/ActCode",
"code": "PBILLACCT"
}
]
},
"valueString": "patient account number in provider's system"
}
],
"employmentImpacted": {
"start": "2017-06-30",
"end": "2017-07-11"
},
"referral": {
"reference": "Practitioner/referringProvider"
},
"hospitalization": {
"start": "2017-06-25",
"end": "2017-06-26"
},
"diagnosis": [
{
"sequence": 1,
"diagnosisCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-10",
"code": "I10"
}
]
}
},
{
"sequence": 2,
"diagnosisCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-10",
"code": "I11.9"
}
]
}
}
],
"related": [
{
"relationship": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-relatedclaimrelationship",
"code": "prior",
"display": "Prior Claim"
}
]
},
"reference": {
"value": "prior claim number goes here"
}
}
],
"item": [
{
"sequence": 1,
"servicedPeriod": {
"start": "1901-01-01",
"end": "1901-01-02"
},
"locationCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-serviceplace",
"code": "11",
"display": "Office"
}
]
},
"service": {
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "99215"
}
]
},
"modifier": {
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "22"
}
]
},
"diagnosisLinkId": 1,
"net": {
"value": 134.34,
"code": "USD",
"system": "urn:iso:std:iso:4217"
},
"quantity": {
"value": 1
},
"careTeamLinkId": 1
}
],
"organization": {
"reference": "Organization/hospital"
},
"total": {
"value": 134.34,
"code": "USD",
"system": "urn:iso:std:iso:4217"
}
}