Simple US Medical Surgery Claim (id = "MED-00050")

<?xml version="1.0" encoding="UTF-8"?>


  

  
    
    
  

  
    
      
      
        
        
        
      
      
      
      
        
        
        
        
        
        
      
    
  

  
    
      

      
        
        
      

      

      
        
          
          
          
        
      

      
        
      

      
        
      

      
        
          
        
      

      
        
        
      

      
        
          
            
        
        
      

      
        
          
            
            
          
        
        
      

    
  

  
    
    
  

  

  
    
      
      
    
  

  
    
      
      
      
    
  

  

  
    
  

  

  
    
      
      
    
    
  

  
    
  

  
    
      
    
  

  
    
      
        
        
      
    
    
      
    
  

  
    
    
      
    
  

  
    
    
      
        
        
      
    
    
      
      
    
  

  
    
    
      
        
        
      
    
    
      
        https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/download
        s/SE0801.pdf
        
        
      
    
  

  
    
    
      
        
        
        
      
    
  

  
    
    
      
        
        
        
      
    
  

  
    
    
      
        
        
        
      
    
  

  
    
    
      
        
        
        
      
    
  

  
    
    
    
      
      
    
      
    
  

  
    
    
    
    
    
    
      
        
        
        
      
    
    
    
      
        
        
        
      
    
    
      
       
     

    
      
       
     
  

  
    
     
   


<Claim xmlns="http://hl7.org/fhir">
  <id value="MED-00050"/> 
  <text> 
    <status value="generated"/> 
    <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of a CMS 1500 Claim</div> 
  </text> 
  <contained> 
    <Patient> 
      <id value="patient-1"/> 
      <name> 
        <use value="official"/> 
        <family value="Ashcraft"/> 
        <given value="Alvina"/> 
      </name> 
      <gender value="female"/> 
      <birthDate value="1954-06-11"/> 
      <address> 
        <use value="home"/> 
        <line value="123 Main Street"/> 
        <city value="Portland"/> 
        <state value="OR"/> 
        <postalCode value="97125"/> 
        <country value="USA"/> 
      </address> 
    </Patient> 
  </contained> 
  <contained> 
    <Coverage> 
      <id value="coverage-1"/> 
      <identifier> 
        <system value="http://benefitsinc.com/certificate"/> 
        <value value="10138556"/> 
      </identifier> 
      <status value="active"/> 
      <kind value="insurance"/> 
      
      <type>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>           <code value="HIP"/>           <display value="health insurance plan policy"/>         </coding>       </type>       <subscriber>         <reference value="#patient-1"/>       </subscriber>       <beneficiary>         <reference value="#patient-1"/>       </beneficiary>       <relationship>         <coding>           <code value="self"/>         </coding>       </relationship>       <period>         <start value="2015-01-01T00:00:00-07:00"/>         <end value="2016-01-01T00:00:00-07:00"/>       </period>       <insurer>         <identifier>           <system value="http://www.bindb.com/bin"/>           <value value="123456"/>           </identifier>         <display value="Humana Inc."/>       </insurer>       <class>         <type>           <coding>             <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>             <code value="group"/>           </coding>         </type>         <value>           <value value="80902206"/>         </value>       </class>     </Coverage>   </contained>   <identifier>     <system value="http://CedarArmsMedicalCenter.com/claim"/>     <value value="MED-00050"/>   </identifier>   <status value="active"/>   <type>     <coding>       <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>       <code value="institutional"/>     </coding>   </type>   <subType>     <coding>       <system value="https://www.cms.gov/codes/billtype"/>       <code value="831"/>       <display value="Hospital Outpatient Surgery performed in an Ambulatory ​Surgical Center"/>     </coding>   </subType>   <use value="claim"/>   <patient>     <reference value="#patient-1"/>   </patient>   <created value="2015-10-16T00:00:00-07:00"/>   <insurer>     <identifier>       <system value="http://www.bindb.com/bin"/>       <value value="123456"/>     </identifier>     <display value="Humana Inc."/>   </insurer>   <provider>     <reference value="Organization/1"/>   </provider>   <priority>     <coding>       <code value="normal"/>     </coding>   </priority>   <payee>     <type>       <coding>         <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>         <code value="provider"/>       </coding>     </type>     <party>       <reference value="Organization/1"/>     </party>   </payee>   <careTeam>     <sequence value="1"/>     <provider>       <reference value="Practitioner/example"/>     </provider>   </careTeam>   <supportingInfo>     <sequence value="1"/>     <category>       <coding>         <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>         <code value="hospitalized"/>       </coding>     </category>     <timingPeriod>       <start value="2015-10-01T00:00:00-07:00"/>       <end value="2015-10-05T00:00:00-07:00"/>     </timingPeriod>   </supportingInfo>   <supportingInfo>     <sequence value="2"/>     <category>       <coding>         <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>         <code value="discharge"/>       </coding>     </category>     <code>       <coding>         <system value="https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/d

        ownloads/SE0801.pdf"/> 
        <code value="01"/>         <display value="Discharge to Home or Self Care"/>       </coding>     </code>   </supportingInfo>   <diagnosis>     <sequence value="1"/>     <diagnosisCodeableConcept>       <coding>         <system value="http://hl7.org/fhir/sid/icd-10-cm"/>         <code value="M96.1"/>         <display value="Postlaminectomy syndrome, not elsewhere classified"/>       </coding>     </diagnosisCodeableConcept>   </diagnosis>   <diagnosis>     <sequence value="2"/>     <diagnosisCodeableConcept>       <coding>         <system value="http://hl7.org/fhir/sid/icd-10-cm"/>         <code value="G89.4"/>         <display value="Chronic pain syndrome"/>       </coding>     </diagnosisCodeableConcept>   </diagnosis>   <diagnosis>     <sequence value="3"/>     <diagnosisCodeableConcept>       <coding>         <system value="http://hl7.org/fhir/sid/icd-10-cm"/>         <code value="M53.88"/>         <display value="Other specified dorsopathies, sacral and sacrococcygeal region"/>       </coding>     </diagnosisCodeableConcept>   </diagnosis>   <diagnosis>     <sequence value="4"/>     <diagnosisCodeableConcept>       <coding>         <system value="http://hl7.org/fhir/sid/icd-10-cm"/>         <code value="M47.816"/>         <display value="Spondylosis without myelopathy or radiculopathy, lumbar region"/>       </coding>     </diagnosisCodeableConcept>   </diagnosis>   <insurance>     <sequence value="1"/>     <focal value="true"/>     <identifier>       <system value="http://CedarArmsMedicalCenter.com/claim"/>       <value value="MED-00050"/>     </identifier>     <coverage>       <reference value="#coverage-1"/>     </coverage>   </insurance>   <item>     <sequence value="1"/>     <careTeamSequence value="1"/>     <diagnosisSequence value="2"/>     <diagnosisSequence value="4"/>     <informationSequence value="1"/>     <productOrService>       <coding>         <system value="http://www.ama-assn.org/go/cpt"/>         <code value="62264"/>         <display value="Surgical Procedures on the Spine and Spinal Cord"/>       </coding>     </productOrService>     <servicedDate value="2015-10-13"/>     <locationCodeableConcept>       <coding>         <system value="https://www.cms.gov/medicare/coding/place-of-service-codes/place_of_service_code_set.html"/>         <code value="24"/>         <display value="Ambulatory Surgical Center"/>       </coding>     </locationCodeableConcept>     <unitPrice>       <value value="12500.00"/>       <currency value="USD"/>      </unitPrice>      <net>       <value value="12500.00"/>       <currency value="USD"/>      </net>    </item>   <total>     <value value="12500.00"/>     <currency value="USD"/>    </total>  


</

Claim

>