CDA Examples
1.0.0 - active
CDA Examples
1.0.0 - active
CDA Examples, published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-Examples/ and changes regularly. See the Directory of published versions
This is an example of how to record multiple CPT Evaluation and Management codes with a single encounter.
This file includes examples of the following templates:
<section xmlns="urn:hl7-org:v3">
<templateId root="2.16.840.1.113883.10.20.22.2.22" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.22"/>
<id root="6c628dae-578b-4e3a-b0d9-e82453d29c14"/>
<code displayName="History of encounters" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="46240-8"/>
<title>Encounters</title>
<text>
<table width="100%">
<thead>
<tr>
<th>Encounter</th>
<th>Provider</th>
<th>Location</th>
<th>Date</th>
<th>Diagnosis</th>
</tr>
</thead>
<tbody>
<tr ID="encounterDescriptionID0">
<td ID="encounterTypeDescriptionID0">Wellness Visit</td>
<td>David E Ford MD</td>
<td/>
<td>09/18/2017</td>
<td>
<content ID="encounterDiagnosisID0">Jaw Asymmetry Maxillary</content>,
<content ID="encounterDiagnosisID1">Anomaly of Dental Arch</content>,
<content ID="encounterDiagnosisID2">Malocclusion Mesio-occlusion</content>
</td>
</tr>
</tbody>
<!-- Some systems may include the CPT E&M code descriptions in the narrative -->
</table>
</text>
<entry typeCode="DRIV">
<encounter moodCode="EVN" classCode="ENC">
<templateId root="2.16.840.1.113883.10.20.22.4.49"
extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<id root="2.16.840.1.113883.3.140.1.1918489287.6.10.16"
extension="449" assigningAuthorityName="Intergy Encounter ID"/>
<id root="2.16.840.1.113883.3.140.1.1918489287.6.10.16.1"
extension="271818" assigningAuthorityName="Intergy Encounter Number"/>
<code displayName="ambulatory" codeSystemName="ActEncounterCode"
codeSystem="2.16.840.1.113883.1.11.13955" code="AMB">
<!-- This is the text the user saw and was the basis for the AMB coding -->
<originalText>
<reference value="#encounterTypeDescriptionID0"/>
</originalText>
</code>
<text>
<reference value="#encounterDescriptionID0"/>
</text>
<effectiveTime>
<low value="20170918093900-0400"/>
<high value="20170918095100-0400"/>
</effectiveTime>
<!-- Could include optional performer -->
<entryRelationship typeCode="COMP">
<!-- Encounter Diagnosis Act -->
<act moodCode="EVN" classCode="ACT">
<templateId root="2.16.840.1.113883.10.20.22.4.80"
extension="2024-05-01"/>
<!-- C-CDA 3.0 -->
<templateId root="2.16.840.1.113883.10.20.22.4.80"
extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.80"/>
<id root="2.16.840.1.113883.3.140.1.1918489287.6.10.7"
extension="449"/>
<code displayName="Diagnosis" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="29308-4"/>
<statusCode code="completed"/>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<observation negationInd="false" moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.4"
extension="2024-05-01"/>
<!-- C-CDA 3.0 -->
<templateId root="2.16.840.1.113883.10.20.22.4.4"
extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="755efd22-a0d1-4504-9e6f-de4e173f91bc"/>
<code xsi:type="CD" displayName="Problem"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="55607006">
<translation xsi:type="CD" displayName="Problem"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
code="75326-9"/>
</code>
<statusCode code="completed"/>
<!-- Better to omit high if problem is ongoing, but if you always include high use nullFlavor=NI -->
<effectiveTime>
<low value="20170918093900-0400"/>
<high nullFlavor="NI"/>
</effectiveTime>
<value xsi:type="CD"
displayName="Asymmetry of maxilla (disorder)" codeSystemName="SNOMED CT"
codeSystem="2.16.840.1.113883.6.96" code="235083001">
<originalText>
<reference value="#encounterDiagnosisID0"/>
</originalText>
<translation xsi:type="CD"
displayName="Jaw Asymmetry Maxillary" codeSystemName="ICD9CM"
codeSystem="2.16.840.1.113883.6.103" code="524.11"/>
<translation xsi:type="CD"
displayName="Jaw Asymmetry Maxillary" codeSystemName="ICD10"
codeSystem="2.16.840.1.113883.6.3" code="M26.11"/>
<translation xsi:type="CD"
displayName="Jaw Asymmetry Maxillary" codeSystemName="MEDCIN"
codeSystem="2.16.840.1.113883.6.26" code="95980"/>
</value>
</observation>
</entryRelationship>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<observation negationInd="false" moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.4"
extension="2024-05-01"/>
<!-- C-CDA 3.0 -->
<templateId root="2.16.840.1.113883.10.20.22.4.4"
extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="c351f35e-ad79-4519-aae2-153526171926"/>
<code xsi:type="CD" displayName="Problem"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="55607006">
<translation xsi:type="CD" displayName="Problem"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
code="75326-9"/>
</code>
<statusCode code="completed"/>
<!-- Better to omit high if problem is ongoing, but if you always include high use nullFlavor=NI -->
<effectiveTime>
<low value="20170918093900-0400"/>
<high nullFlavor="NI"/>
</effectiveTime>
<value xsi:type="CD"
displayName="Anomaly of dental arch (disorder)" codeSystemName="SNOMED CT"
codeSystem="2.16.840.1.113883.6.96" code="23997001">
<originalText>
<reference value="#encounterDiagnosisID1"/>
</originalText>
<translation xsi:type="CD"
displayName="Anomaly of Dental Arch" codeSystemName="ICD9CM"
codeSystem="2.16.840.1.113883.6.103" code="524.20"/>
<translation xsi:type="CD"
displayName="Anomaly of Dental Arch" codeSystemName="MEDCIN"
codeSystem="2.16.840.1.113883.6.26" code="312141"/>
</value>
</observation>
</entryRelationship>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<observation negationInd="false" moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.4"
extension="2024-05-01"/>
<!-- C-CDA 3.0 -->
<templateId root="2.16.840.1.113883.10.20.22.4.4"
extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="1dd3d744-6108-4284-823a-138c2568e446"/>
<code xsi:type="CD" displayName="Problem"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="55607006">
<translation xsi:type="CD" displayName="Problem"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
code="75326-9"/>
</code>
<statusCode code="completed"/>
<!-- Better to omit high if problem is ongoing, but if you always include high use nullFlavor=NI -->
<effectiveTime>
<low value="20170918093900-0400"/>
<high nullFlavor="NI"/>
</effectiveTime>
<value xsi:type="CD"
displayName="Mesio-occlusion of teeth (disorder)" codeSystemName="SNOMED CT"
codeSystem="2.16.840.1.113883.6.96" code="12264001">
<originalText>
<reference value="#encounterDiagnosisID2"/>
</originalText>
<translation xsi:type="CD"
displayName="Malocclusion Mesio-occlusion" codeSystemName="ICD9CM"
codeSystem="2.16.840.1.113883.6.103" code="524.23"/>
<translation xsi:type="CD"
displayName="Malocclusion Mesio-occlusion" codeSystemName="ICD10"
codeSystem="2.16.840.1.113883.6.3" code="M26.213"/>
<translation xsi:type="CD"
displayName="Malocclusion Mesio-occlusion" codeSystemName="MEDCIN"
codeSystem="2.16.840.1.113883.6.26" code="219237"/>
</value>
</observation>
</entryRelationship>
</act>
</entryRelationship>
<entryRelationship typeCode="REFR" inversionInd="false">
<act moodCode="EVN" classCode="ACT">
<code
displayName="Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"
code="99408"/>
</act>
</entryRelationship>
<entryRelationship typeCode="REFR" inversionInd="false">
<act moodCode="EVN" classCode="ACT">
<code
displayName="Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"
code="99394"/>
</act>
</entryRelationship>
<entryRelationship typeCode="REFR" inversionInd="false">
<act moodCode="EVN" classCode="ACT">
<code
displayName="Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter." codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"
code="99213"/>
</act>
</entryRelationship>
</encounter>
</entry>
</section>
IG © Health Level Seven. Package hl7.cda.examples#1.0.0 based on FHIR 5.0.0. Generated 2025-08-28
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