Reason for Referral - SNOMED code and Indication required or optional???

[kylem...@gmail.com]

In the USCDI v3 test data, our girl Alice Newman has her reason for referral code as SNOMED 310449005. Also, the Indication Code for Referral notes it should be Fever in the Problem List. Both of those elements are NOT in brackets meaning they are required and not optional.

In the main USCDI page, it does not have a vocabulary standard listed for Reason for Referral. When you get to the CCDA Companion Guide, it says "follow C-CDA" and in the xPath location refers to the Patient Referral Act (where the SNOMED coded referral location would go) and the Indication observation (where the Fever diagnosis would go).

My question is MUST a 315.b.1 USCDI v3-compliant EHR be able to map into the CCDA a SNOMED Referral Code as well as include Indication (which will be SNOMED coded too) per those xPath locations. OR, is it permissible for an EHR to only record the reason for referral as narrative text?

I've attached 2 examples - the "simple" version for referral with just narrative text and the "complete" version including those two xPath locations with SNOMED Codes. Is the understanding of the group that the "complete" version would be compliant while the "basic" would not? (BTW, I recognize that it acceptable to not always include the Patient Referral Act nor the Indication especially if the provider does not document it but my question is regarding the CAPABILITY to do this as in an EHR can NEVER added this referral information as SNOMED - would that EHR be compliant?).

My understanding is that an EHR must be able to do the "complete" option, but I wanted to ask others. Thanks. 

Kyle

Chart Lux Consulting

[Kim Poletti]

Hi - Thanks for reaching out. This has been logged for review and a member of the team will reach out in the near future.

[kylem...@gmail.com]

Thanks for looking into it. Based on the current version of the test tool, it will throw an error for AliceNewman file if the Patient Referral Act is missing, but it will not throw an error if the Indication observation is missing. 

Kyle

[Ivan Quan]

Hi - I am reaching out for the same reason as Kyle mentioned in this conversation. Do we have an answer yet?

Thanks,

Ivan

[Arslan Iqbal]

SITE/ETT team's internal reference SITE-4550

[Ivan Quan]

I do not have permission to access that ticket.

[Arslan Iqbal]

That's an internal working project for the SITE/ETT team, inaccessible to external users. We started capturing the internal tickets' links in google groups threads so the team can easily look up the related tickets as needed. We'll continue sharing public updates here

[Dmitry Shalimov]

Hello, 

I have the same question.

ETT team, do you know when we could expect a response to this?

Thanks,

Dmitry

[Brenda Millet]

Hello, 

Has there been any update on this? This is posing as a blocker in development for a current client of ours.   Will you be releasing updated test data documents along with the test tool updates?

Thank you for your attention to this matter.  

- Drummond Group

[Kim Poletti]

Hello,

As per guidance from ASTP, both referral and indication codes are required for compliance. Test data will be updated in a future release.

Please let us know if you have further questions.

Thank you,

Kim

[Michelle Knighton]

Can you please provide linkage to the ASTP guidance? I can find no regulatory basis that would support requiring a coded indication rather than simply allowing the narrative. USCDIv3 indicates Reason for Referral is required, but has no associated standard and CCDA indicates this is a MAY requirement. Further, there is no regulation text that requires a code be associated with Reason for Referral. The regulation simply states there is a need for ambulatory EHRs to support Reason for Referral; no standard required. Finally, there is no guidance in the b1 CCG that supports use of a code for Reason for Referral rather than the narrative. 

Michelle

[Kim Poletti]

Hello Michelle,

After checking with ASTP staff, they provided this further guidance:

"Transitions of care criterion §170.315(b)(1) requires Health IT Modules to demonstrate the capability to generate C-CDA documents that include all required sections and data elements as specified by USCDI v3, which includes "Reason for Referral." C-CDA allows for flexibility in how this information can be presented, because there are scenarios where codes are optional. Health IT modules must be capable of showing "Reason for Referral" can be represented in both narrative text and code form."

Please let us know if you have further questions.

Thank you,

Kim

[Marcie Runyan]

Hi Kim, 

I've placed an inquiry with ASTP to inquire on this as well, but I did want to flag the following information in the (b)(1) Transitions of Care Test Procedure. This, in combination with the fact that developers are only required to support USCDIv3 and that the USCDIv3 applicable vocabulary standard offers flexibility for “reason for referral,” suggests that SNOMED is optional. Only in USCDIv4 is SNOMED listed as the applicable vocabulary standard. Would it be possible to revisit this with ASTP on your end? 

Thank you again for reviewing this matter to date. 

-Marcie Runyan