Common CQL Artifacts for FHIR (US-Based)
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Common CQL Artifacts for FHIR (US-Based), published by HL7 International / Clinical Decision Support. This guide is not an authorized publication; it is the continuous build for version 2.0.0-cibuild built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/us-cql-ig/ and changes regularly. See the Directory of published versions

Questionnaire: Example Medical Necessity For Authorization Of Catheters Questionnaire (Experimental)

Official URL: http://hl7.org/fhir/us/cql/Questionnaire/MNACQuestionnaire Version: 2.0.0-cibuild
Standards status: Informative Active as of 2024-01-17 Computable Name: MNACQuestionnaire

Copyright/Legal: This content is informed by the following source, used with permission: https://www.hca.wa.gov/assets/billers-and-providers/13-760.pdf

This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.

Structure
LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. MNACQuestionnaire This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form. Questionnaire http://hl7.org/fhir/us/cql/Questionnaire/MNACQuestionnaire#2.0.0-cibuild
... request-info Request Information 0..1 group Value Set:
.... request-info|date-of-request DATE OF REQUEST 0..1 date Value Set:
... diagnosis-info Diagnosis Information 0..1 group Value Set:
.... diagnosis-info|diagnosis Diagnosis 0..1 string Value Set:
... item-requested Item Requested 0..1 group Value Set:
.... item-requested|item Item requested 0..1 string Value Set:
.... uti-history|uti-last-year The patient has|had documented recurrent urinary tract infections while on a program of clean cathing, twice within a 12 month period prior to beginning sterile cathing 0..1 boolean Value Set:
.... uti-history|uti-dates Dates of UTIs in the last year 0..1 string Enable When: uti-history|uti-last-year = true
Value Set:
.... uti-history|antibiotics-used Antibiotics used for UTIs in the last year 0..1 string Enable When: uti-history|uti-last-year = true
Value Set:
... symptoms-info Symptoms Information 0..1 group Value Set:
.... symptoms-info|symptoms Check those that apply to your patient 0..* choice Value Set:
Options: 7 options
.... symptoms-info|fever-temperature If fever, state temperature in degrees 0..1 decimal Enable When: symptoms-info|symptoms = Fever (MNACQuestionnaire-symptoms-info-symptoms#Fever)
Value Set:
... catheterization-frequency Catheterization Frequency 0..1 group Value Set:
.... catheterization-frequency|frequency How many times per day does the patient catheterize? 0..1 choice Value Set:
Options: 4 options
... additional-comments Additional Comments 0..1 group Value Set:
.... additional-comments|comments Additional Comment 0..1 string Value Set:
... physician-info Physician Information 0..1 group Value Set:
.... physician-info|name Physician's Name 0..1 string Value Set:
.... physician-info|mobile Telephone 0..1 string Value Set:
.... physician-info|fax FAX 0..1 string Value Set:
.... physician-info|signature Physician's Signature 0..1 attachment Value Set:
.... physician-info|phone-referring Referring Physician Telephone 0..1 string Value Set:
.... physician-info|date Date 0..1 string Value Set:

doco Documentation for this format

Options Sets

Answer options for symptoms-info|symptoms

  • http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#Fever ("Fever; state temperature in degree")
  • http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#UrinaryUrgencyFrequency ("Change in urinary urgency, frequency, or incontinence")
  • http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#AutonomicDysreflexia ("Appearance of new or increase in autonomic dysreflexia")
  • http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#PhysicalSignsProstatitis ("Physical signs of prostatitis, epididymitis, orchitis")
  • http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#Immunosuppressed ("The patient is immunosuppressed")
  • http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#Pyuria ("Pyuria")
  • http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#SystemicLeukocytosis ("Systemic leukocytosis")

Answer options for catheterization-frequency|frequency

  • http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency#2-4Times ("2-4 times")
  • http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency#4-6Times ("4-6 times")
  • http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency#6-8Times ("6-8 times")
  • http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency#8TimesOrMore ("8 times or more")

Request Information

  • linkId: request-info
  • Answers:

DATE OF REQUEST

  • linkId: request-info|date-of-request
  • Answers:

Diagnosis Information

  • linkId: diagnosis-info
  • Answers:

Diagnosis

  • linkId: diagnosis-info|diagnosis
  • Answers:

Item Requested

  • linkId: item-requested
  • Answers:

Item requested

  • linkId: item-requested|item
  • Answers:

UTI History

  • linkId: uti-history
  • Answers:

The patient has|had documented recurrent urinary tract infections while on a program of clean cathing, twice within a 12 month period prior to beginning sterile cathing

  • linkId: uti-history|uti-last-year
  • Answers:

Dates of UTIs in the last year

  • linkId: uti-history|uti-dates
  • Enable When: todo
  • Answers:

Antibiotics used for UTIs in the last year

  • linkId: uti-history|antibiotics-used
  • Enable When: todo
  • Answers:

Symptoms Information

  • linkId: symptoms-info
  • Answers:

Check those that apply to your patient

If fever, state temperature in degrees

  • linkId: symptoms-info|fever-temperature
  • Enable When: todo
  • Answers:

Catheterization Frequency

  • linkId: catheterization-frequency
  • Answers:

How many times per day does the patient catheterize?

Additional Comments

  • linkId: additional-comments
  • Answers:

Additional Comment

  • linkId: additional-comments|comments
  • Answers:

Physician Information

  • linkId: physician-info
  • Answers:

Physician's Name

  • linkId: physician-info|name
  • Answers:

Telephone

  • linkId: physician-info|mobile
  • Answers:

FAX

  • linkId: physician-info|fax
  • Answers:

Physician's Signature

  • linkId: physician-info|signature
  • Answers:

Referring Physician Telephone

  • linkId: physician-info|phone-referring
  • Answers:

Date

  • linkId: physician-info|date
  • Answers:

LinkIDDescription & Constraintsdoco
.. request-info Value Set:
... request-info|date-of-request Value Set:
.. diagnosis-info Value Set:
... diagnosis-info|diagnosis Value Set:
.. item-requested Value Set:
... item-requested|item Value Set:
.. uti-history Value Set:
... uti-history|uti-last-year Value Set:
... uti-history|uti-dates Enable When: Not done yet
Value Set:
... uti-history|antibiotics-used Enable When: Not done yet
Value Set:
.. symptoms-info Value Set:
... symptoms-info|symptoms Value Set:
Options: 7 options
... symptoms-info|fever-temperature Enable When: Not done yet
Value Set:
.. catheterization-frequency Value Set:
... catheterization-frequency|frequency Value Set:
Options: 4 options
.. additional-comments Value Set:
... additional-comments|comments Value Set:
.. physician-info Value Set:
... physician-info|name Value Set:
... physician-info|mobile Value Set:
... physician-info|fax Value Set:
... physician-info|signature Value Set:
... physician-info|phone-referring Value Set:
... physician-info|date Value Set:

doco Documentation for this format

Contained resources

Test this Questionnaire

Try this questionnaire out:

Responses for this Questionnaire

There are currently no QuestionnaireResponse instances for this Questionnaire defined in this IG.