Representing form CMS 1500 as FHIR


#1

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:

  1. 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)”
  2. 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"
  }
}

#2

Hi @Craig_Finch:

Can you join the Financial Management committee conference call on Friday at 1:00 PM Eastern to review?


#3

@pknapp Thank you for the invitation. I have an overlapping meeting, but I’ll try to fit it in. Please let me know how to join.


#4

@Craig_Finch: FreeConferenceCall.com meeting code fm4.


#5

Instructions regarding field 24i:

24i Code descriptors: If the provider does not have an NPI, enter the appropriate qualifier and identifying number in the shaded area. There will always be providers who do not have an NPI and will need to report non-NPI identifiers on their claim forms. The qualifiers will indicate the non-NPI number being reported.
The NUCC defines the following qualifiers used in 5010A1:
0B State License Number
1G Provider UPIN Number
G2 Provider Commercial Number
LU Location Number
ZZ Provider Taxonomy (The qualifier in the 5010A1 for Provider Taxonomy is PXC, but ZZ will remain the qualifier for the 1500 Claim Form. Note: This identifier is not included in this data element in 5010A1.)

Source: http://www.nucc.org/images/stories/PDF/1500_claim_form_instruction_manual_2012_02.pdf (page 29)