LinkID | Text | Definition | Answer |
---|
home-o2-questionnaireresponse | | | Questionnaire:Referred Questionnaire for QuestionnaireResponse |
1 | Patient Information | | |
1.1 | Last Name but Different This Time | | Quinton |
1.2 | First Name | | Vlad |
1.3 | Middle Initial | | A, N |
1.4 | Date Of Birth | | 1956-12-01 |
1.5 | Gender | | AdministrativeGender male: Male |
1.6 | Medicare ID | | 10A3D58WH22 |
2 | Provider who is performing face-to-face evaluation | | |
2.1 | Last Name | | Doe |
2.2 | First Name | | Jane |
2.3 | Middle Initial | | B |
2.4 | NPI | | 1122334455 |
2.5 | Date of Face-To-Face Evaluation | | 2019-07-18 |
2.6 | Record | | Mr. Saul Moki |
3 | Coverage Requirements | | |
3.1 | Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy) | | SNOMED CT 313296004: Mild chronic obstructive pulmonary disease |
3.2 | Arterial oxygen saturation (Patient on room air while at rest and awake when tested) | | 95 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]') |
3.3 | Arterial Partial Pressure of Oxygen (PO2) (Patient on room air while at rest and awake when tested) | | 83 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]') |
3.4 | Arterial oxygen saturation (Patient tested during exercise) | | 95 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]') |
3.5 | Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise) | | 78 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]') |
3.6 | Is there a documented improvement of hypoxemia during exercise with oxygen? | | true |
4 | Prescribed Use | | |
4.1 | Start date | | 2019-07-18 |
4.2 | Length of need: (months) (99 = lifetime) | | 99 |
4.3 | Peak Flow Rate | | |
4.3.1 | LPM | | 2 |
4.3.2 | oxygen % | | 98 |
4.4 | Average Flow Rate | | |
4.4.1 | LPM | | 2 |
4.4.2 | oxygen % | | 97 |
4.5 | Frequency of use (choose all that apply) | | At rest and awake |
5 | Oxygen Supply Order Details | | |
5.1 | Current Order Description | | HCPCS E0424 - Stationary Compressed Gaseous Oxygen System, Rental |
5.1b | Current Order Is For A Portable Device | | |
5.2 | Type | | example.org 122: Compressed Gas |
5.3 | Means of oxygen delivery and accessories | | example.org 134: Mask |
Documentation for this format |