This is captured by adding a procedure with a valid CPT and/or SNOMED code using the procedure widget in a note.

98969Online assessment and management service provided by a qualified nonphysician health care professional to an established patient or guardian, not originating from a related assessment and management service provided within the previous 7 days, using the Internet or similar electronic communications network

CPT:
Code	Description
98966	Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
98967	Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion
98968	Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion
98970	Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
98971	Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes
98972	Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes
99201	Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
99202	Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family.
99203	Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.
99204	Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.
99205	Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.
99212	Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
99213	Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.
99214	Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.
99215	Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.
99241	Office consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 15 minutes are spent face-to-face with the patient and/or family.
99242	Office consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.
99243	Office consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.
99244	Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.
99245	Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent face-to-face with the patient and/or family.
99341	Home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent face-to-face with the patient and/or family.
99342	Home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.
99343	Home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.
99344	Home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.
99345	Home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent face-to-face with the patient and/or family.
99347	Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 15 minutes are spent face-to-face with the patient and/or family.
99348	Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.
99349	Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.
99350	Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face with the patient and/or family.
99385	Initial comprehensive preventive medicine evaluation 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, new patient; 18-39 years
99386	Initial comprehensive preventive medicine evaluation 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, new patient; 40-64 years
99387	Initial comprehensive preventive medicine evaluation 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, new patient; 65 years and older
99395	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; 18-39 years
99396	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; 40-64 years
99397	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; 65 years and older
99421	Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
99422	Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes
99423	Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes
99441	Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
99442	Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion
99443	Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion
99458	Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes (List separately in addition to code for primary procedure)
G0071	Payment for communication technology-based services for 5 minutes or more of a virtual (non-face-to-face) communication between an rural health clinic (rhc) or federally qualified health center (fqhc) practitioner and rhc or fqhc patient, or 5 minutes or more of remote evaluation of recorded video and/or images by an rhc or fqhc practitioner, occurring in lieu of an office visit; rhc or fqhc only
G0438	Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit
G0439	Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit
G2010	Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment
G2012	Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
G2061	Qualified nonphysician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes
G2062	Qualified nonphysician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11-20 minutes
G2063	Qualified nonphysician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes

 

SNOMED:
Code	Description
12843005	Subsequent hospital visit by physician (procedure)
18170008	Subsequent nursing facility visit (procedure)
185317003	Telephone encounter (procedure)
19681004	Nursing evaluation of patient and report (procedure)
314849005	Telephone contact by consultant (procedure)
386472008	Telephone consultation (procedure)
386473003	Telephone follow-up (procedure)
401267002	Telephone triage encounter (procedure)
4525004	Emergency department patient visit (procedure)
87790002	Follow-up inpatient consultation visit (procedure)
90526000	Initial evaluation and management of healthy individual (procedure)
185349003	Encounter for “check-up” (procedure)
185463005	Visit out of hours (procedure)
185465003	Weekend visit (procedure)
207195004	History and physical examination with evaluation and management of nursing facility patient (procedure)
270427003	Patient-initiated encounter (procedure)
270430005	Provider-initiated encounter (procedure)
308335008	Patient encounter procedure (procedure)
390906007	Follow-up encounter (procedure)
406547006	Urgent follow-up (procedure)
185460008	Home visit request by patient (procedure)
185462000	Home visit request by relative (procedure)
185466002	Home visit for urgent condition (procedure)
185467006	Home visit for acute condition (procedure)
185468001	Home visit for chronic condition (procedure)
185470005	Home visit elderly assessment (procedure)
225929007	Joint home visit (procedure)
315205008	Bank holiday home visit (procedure)
439708006	Home visit (procedure)
698704008	Home visit for rheumatology service (procedure)
704126008	Home visit for anticoagulant drug monitoring (procedure)
185463005	Visit out of hours (procedure)
185464004	Out of hours visit – not night visit (procedure)
185465003	Weekend visit (procedure)
30346009	Evaluation and management of established outpatient in office or other outpatient facility (procedure)
3391000175108	Office visit for pediatric care and assessment (procedure)
37894004	Evaluation and management of new outpatient in office or other outpatient facility (procedure)
439740005	Postoperative follow-up visit (procedure)
444971000124105	Annual wellness visit (procedure)
456201000124103	Medicare Annual Wellness Visit (procedure)

This is captured by adding a diagnosis with a valid ICD10 or SNOMED code using the diagnosis widget in a note.

ICD-10:
Code	Description
I10	Essental (primary) hypertension

 

SNOMED:
Code	Description
10725009	Benign hypertension (disorder)
1078301000112109	Multiple drug intolerant hypertension (disorder)
1201005	Benign essential hypertension (disorder)
276789009	Labile hypertension (disorder)
371125006	Labile essential hypertension (disorder)
429457004	Systolic essential hypertension (disorder)
461301000124109	Resistant hypertensive disorder (disorder)
46481004	Low-renin essential hypertension (disorder)
48146000	Diastolic hypertension (disorder)
56218007	Systolic hypertension (disorder)
59621000	Essential hypertension (disorder)
59720008	Sustained diastolic hypertension (disorder)
65518004	Labile diastolic hypertension (disorder)
762463000	Diastolic hypertension co-occurrent with systolic hypertension (disorder)
78975002	Malignant essential hypertension (disorder)

This is captured by adding a diagnosis with a valid ICD10 or SNOMED code using the diagnosis widget in a note.

ICD-10:
Code	Description
N18.6	End stage renal disease
SNOMED:
Code	Description
46177005	End stage renal disease (disorder)
236434000	End stage renal failure untreated by renal replacement therapy (disorder)
236435004	End stage renal failure on dialysis (disorder)
236436003	End stage renal failure with renal transplant (disorder)

This is captured by adding a diagnosis with a valid ICD10 or SNOMED code using the diagnosis widget in a note.

ICD-10:
Code	Description
N18.5	Chronic kidney disease, stage 5
SNOMED:
Code	Description
433146000	Chronic kidney disease stage 5 (disorder)

This is captured by adding a procedure with a valid CPT/HCPCS and/or SNOMED code using the procedure widget in a note.

CPT/HCPCS:
Code	Description
90935	Hemodialysis procedure with single evaluation by a physician or other qualified health care professional
90937	Hemodialysis procedure requiring repeated evaluation(s) with or without substantial revision of dialysis prescription
90945	Dialysis procedure other than hemodialysis (eg, peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies), with single evaluation by a physician or other qualified health care professional
90947	Dialysis procedure other than hemodialysis (eg, peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies) requiring repeated evaluations by a physician or other qualified health care professional, with or without substantial revision of dialysis prescription
90997	Hemoperfusion (eg, with activated charcoal or resin)
90999	Unlisted dialysis procedure, inpatient or outpatient
99512	Home visit for hemodialysis
G0257	Unscheduled or emergency dialysis treatment for an esrd patient in a hospital outpatient department that is not certified as an esrd facility
S9339	Home therapy; peritoneal dialysis, administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

 

SNOMED:
Code	Description
108241001	Dialysis procedure (procedure)
10848006	Removal of peritoneal dialysis catheter (procedure)
11932001	Stabilizing hemodialysis (procedure)
14684005	Peritoneal dialysis excluding cannulation (procedure)
180273006	Removal of chronic ambulatory peritoneal dialysis catheter (procedure)
225230008	Chronic peritoneal dialysis (procedure)
225231007	Stab peritoneal dialysis (procedure)
233575001	Intermittent hemodialysis (procedure)
233576000	Intermittent hemodialysis with sequential ultrafiltration (procedure)
233577009	Intermittent hemodialysis with continuous ultrafiltration (procedure)
233578004	Continuous hemodialysis (procedure)
233579007	Continuous arteriovenous hemodialysis (procedure)
233580005	Continuous venovenous hemodialysis (procedure)
233581009	Hemofiltration (procedure)
233582002	Intermittent hemofiltration (procedure)
233583007	Continuous hemofiltration (procedure)
233584001	Continuous arteriovenous hemofiltration (procedure)
233585000	Continuous venovenous hemofiltration (procedure)
233586004	Hemodiafiltration (procedure)
233587008	Intermittent hemodiafiltration (procedure)
233588003	Continuous hemodiafiltration (procedure)
233589006	Continuous arteriovenous hemodiafiltration (procedure)
233590002	Continuous venovenous hemodiafiltration (procedure)
238316008	Aspiration of chronic ambulatory peritoneal dialysis catheter (procedure)
238317004	Flushing of chronic ambulatory peritoneal dialysis catheter (procedure)
238318009	Continuous ambulatory peritoneal dialysis (procedure)
238319001	Continuous cycling peritoneal dialysis (procedure)
238321006	Intermittent peritoneal dialysis (procedure)
238322004	Tidal peritoneal dialysis (procedure)
238323009	Night-time intermittent peritoneal dialysis (procedure)
265764009	Renal dialysis (procedure)
288182009	Extracorporeal kidney (procedure)
302497006	Hemodialysis (procedure)
34897002	Hemodialysis, maintenance in hospital (procedure)
427053002	Extracorporeal albumin hemodialysis (procedure)
428648006	Automated peritoneal dialysis (procedure)
439278006	Measurement of static venous pressure in hemodialysis vascular access (procedure)
439976001	Measurement of recirculation in hemodialysis vascular access (procedure)
57274006	Initial hemodialysis (procedure)
676002	Peritoneal dialysis including cannulation (procedure)
67970008	Hemodialysis, maintenance at home (procedure)
68341005	Hemodialysis, supervision at home (procedure)
71192002	Peritoneal dialysis (procedure)
714749008	Continuous renal replacement therapy (procedure)

This is captured by adding a procedure with a valid CPT code using the procedure widget in a note.

CPT:
Code	Description
90951	End-stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face visits by a physician or other qualified health care professional per month
90952	End-stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2-3 face-to-face visits by a physician or other qualified health care professional per month
90953	End-stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face visit by a physician or other qualified health care professional per month
90954	End-stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face visits by a physician or other qualified health care professional per month
90955	End-stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2-3 face-to-face visits by a physician or other qualified health care professional per month
90956	End-stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face visit by a physician or other qualified health care professional per month
90957	End-stage renal disease (ESRD) related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face visits by a physician or other qualified health care professional per month
90958	End-stage renal disease (ESRD) related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2-3 face-to-face visits by a physician or other qualified health care professional per month
90959	End-stage renal disease (ESRD) related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face visit by a physician or other qualified health care professional per month
90960	End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 4 or more face-to-face visits by a physician or other qualified health care professional per month
90961	End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 2-3 face-to-face visits by a physician or other qualified health care professional per month
90962	End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 1 face-to-face visit by a physician or other qualified health care professional per month
90963	End-stage renal disease (ESRD) related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents
90964	End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents
90965	End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents
90966	End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 20 years of age and older
90967	End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients younger than 2 years of age
90968	End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 2-11 years of age
90969	End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 12-19 years of age
90970	End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 20 years of age and older
90989	Dialysis training, patient, including helper where applicable, any mode, completed course
90993	Dialysis training, patient, including helper where applicable, any mode, course not completed, per training session
90997	Hemoperfusion (eg, with activated charcoal or resin)
90999	Unlisted dialysis procedure, inpatient or outpatient
99512	Home visit for hemodialysis

This is captured by adding a procedure with a valid CPT/HCPCS and/or SNOMED code using the procedure widget in a note.

CPT/HCPCS:
Code	Description
50360	Renal allotransplantation, implantation of graft; without recipient nephrectomy
50365	Renal allotransplantation, implantation of graft; with recipient nephrectomy
50380	Renal autotransplantation, reimplantation of kidney
S2065	Simultaneous pancreas kidney transplantation

 

SNOMED:
Code	Description
175899003	Autotransplantation of kidney (procedure)
175901007	Live donor renal transplant (procedure)
175902000	Cadaveric renal transplant (procedure)
236138007	Xenograft renal transplant (procedure)
313030004	Donor renal transplantation (procedure)
52213001	Renal homotransplantation excluding donor and recipient nephrectomy (procedure)
6471000179103	Transplantation of kidney and pancreas (procedure)
70536003	Transplant of kidney (procedure)
711411006	Allotransplantation of kidney from beating heart cadaver (procedure)
711413009	Allotransplantation of kidney from non-beating heart cadaver (procedure)
765478004	Allotransplantation of left kidney (procedure)
765479007	Allotransplantation of right kidney (procedure)
782655004	Laparoscopic transplant of kidney using robotic assistance (procedure)

This is captured by adding a diagnosis with a valid ICD10 or SNOMED code using the diagnosis widget in a note.

ICD10:
Code	Description
Z94.0	Kidney transplant status

 

SNOMED:
Code	Description
161665007	History of renal transplant (situation)

To meet the requirements for this exclusion patients must be 81 years or older, AND a Frailty Device (SNOMED); or a Frailty Diagnosis, or a Frailty Symptom (ICD10 or SNOMED); or a Frailty Encounter (CPT/HCPCS) must have been entered in the patient’s chart during the measurement period.

Frailty Device

SNOMED:
Code	Description
183240000	Self-propelled wheelchair (physical object)
183241001	Pedal powered wheelchair (physical object)
183248007	Attendant powered wheelchair (physical object)
228869008	Manual wheelchair (physical object)
23366006	Motorized wheelchair device (physical object)
23562009	Household ventilator, device (physical object)
261323006	Portable oxygen cylinder (physical object)
262177002	Static oxygen cylinder (physical object)
360006004	Walking stick (physical object)
360008003	Commode (physical object)
360299009	Long cane (physical object)
371786002	Pressure support ventilator (physical object)
37874008	Continuing positive airway pressure unit, device (physical object)
391685000	Oxygen gas cylinder DD (physical object)
391686004	Oxygen gas cylinder HD (physical object)
391687008	Oxygen gas cylinder RD (physical object)
391688003	Oxygen gas cylinder DF (physical object)
391689006	Oxygen gas cylinder HX (physical object)
391880008	Oxygen gas cylinder F (physical object)
391881007	Oxygen gas cylinder AF (physical object)
401953003	Oxygen composite cylinder with integral headset 1360 liters (physical object)
401954009	Oxygen cylinder 1360 liters (physical object)
401955005	Oxygen cylinder 300 liters (physical object)
426160001	Oxygen ventilator (physical object)
462987000	Patient/medical device walker (physical object)
463093001	Patient/medical device walker, home-use (physical object)
464002006	Portable ventilator, electric (physical object)
464157006	Multiple-base walking stick (physical object)
464405003	Multi-terrain sports wheelchair, attendant/occupant-driven (physical object)
464443000	Stand-up wheelchair (physical object)
464571009	Multi-terrain sports wheelchair, electric-motor-driven (physical object)
464752005	Multi-terrain sports wheelchair, occupant-driven (physical object)
465159000	Stair-climbing wheelchair (physical object)
465556004	Single-base walking stick (physical object)
465565006	Transport wheelchair, collapsible (physical object)
465921009	Ventilation rocking bed (physical object)
466182009	Wheelchair, occupant-driven, front-wheels-operated, non-collapsible (physical object)
466193006	Wheelchair, power-assisted, occupant-controlled, non-collapsible (physical object)
466213002	Wheelchair, electric-motor-driven, occupant-controlled, manual-steering, collapsible (physical object)
466229005	Wheelchair, occupant-driven, bimanual-lever-operated, non-collapsible (physical object)
466284002	Wheelchair, attendant/occupant-driven, bimanual-lever-operated, collapsible (physical object)
466316007	Wheelchair, combustion-engine-driven, non-collapsible (physical object)
466317003	Basic walker, foldable (physical object)
466322003	Wheelchair, power-assisted, attendant/occupant-controlled, non-collapsible (physical object)
466331003	Wheelchair, attendant/occupant-driven, single-rear-wheel-operated, non-collapsible (physical object)
466337004	Wheelchair, attendant/occupant-driven, foot-operated, non-collapsible (physical object)
466340004	Wheelchair, occupant-driven, bimanual-lever-operated, collapsible (physical object)
466344008	Wheelchair, electric-motor-driven, occupant-controlled, powered-steering, non-collapsible (physical object)
466351004	Walking chair, foldable (physical object)
466364003	Wheelchair, attendant/occupant-driven, rear-wheels-operated, collapsible (physical object)
466365002	Wheelchair, electric-motor-driven, attendant/occupant-controlled, manual-steering, collapsible (physical object)
466366001	Wheelchair, attendant/occupant-driven, single-lever-operated, non-collapsible (physical object)
466378002	Wheelchair, electric-motor-driven, occupant-controlled, powered-steering, collapsible (physical object)
466381007	Wheelchair, attendant-driven, non-collapsible (physical object)
466407009	Walking stick/seat (physical object)
466464004	Basic walker, non-foldable (physical object)
466466002	Wheelchair, occupant-driven, foot-operated, collapsible (physical object)
466473007	Wheelchair, electric-motor-driven, attendant-controlled, manual-steering, collapsible (physical object)
466477008	Wheelchair, electric-motor-driven, occupant-controlled, manual-steering, non-collapsible (physical object)
466486003	Wheelchair, attendant/occupant-driven, bimanual-lever-operated, non-collapsible (physical object)
466494005	Wheelchair, power-assisted, attendant-controlled, collapsible (physical object)
466524001	Wheelchair, attendant-driven, collapsible (physical object)
466533004	Wheelchair, attendant/occupant-driven, foot-operated, collapsible (physical object)
466538008	Room humidifier (physical object)
466550002	Wheelchair, attendant/occupant-driven, rear-wheels-operated, non-collapsible (physical object)
466553000	Wheelchair, occupant-driven, single-lever-operated, collapsible (physical object)
466576002	Wheelchair, occupant-driven, bimanual-chain-operated, collapsible (physical object)
466607002	Wheelchair, attendant/occupant-driven, single-lever-operated, collapsible (physical object)
466616003	Wheelchair, attendant/occupant-driven, single-rear-wheel-operated, collapsible (physical object)
466619005	Wheelchair, attendant/occupant-driven, bimanual-chain-operated, non-collapsible (physical object)
466644002	Wheelchair, occupant-driven, bimanual-chain-operated, non-collapsible (physical object)
466671002	Wheelchair, combustion-engine-driven, collapsible (physical object)
466695000	Wheelchair, attendant/occupant-driven, single-front-wheel-operated, collapsible (physical object)
466699006	Wheelchair, power-assisted, attendant/occupant-controlled, collapsible (physical object)
466721007	Wheelchair, power-assisted, attendant-controlled, non-collapsible (physical object)
466739003	Wheelchair, occupant-driven, front-wheels-operated, collapsible (physical object)
466758007	Wheelchair, electric-motor-driven, attendant-controlled, manual-steering, non-collapsible (physical object)
466786004	Basic electric hospital bed (physical object)
466809001	Wheelchair, attendant/occupant-driven, bimanual-chain-operated, collapsible (physical object)
466813008	Wheelchair, electric-motor-driven, attendant-controlled, powered-steering, non-collapsible (physical object)
466851008	Wheelchair, attendant/occupant-driven, front-wheels-operated, collapsible (physical object)
466871004	Wheelchair, electric-motor-driven, attendant/occupant-controlled, powered-steering, non-collapsible (physical object)
466889003	Wheelchair, attendant/occupant-driven, single-front-wheel-operated, non-collapsible (physical object)
466926008	Wheelchair, occupant-driven, rear-wheels-operated, collapsible (physical object)
466927004	Wheelchair, electric-motor-driven, attendant/occupant-controlled, powered-steering, collapsible (physical object)
466938004	Wheelchair, occupant-driven, single-rear-wheel-operated, collapsible (physical object)
466947007	Wheelchair, occupant-driven, rear-wheels-operated, non-collapsible (physical object)
466966007	Wheelchair, occupant-driven, foot-operated, non-collapsible (physical object)
466986006	Walking table (physical object)
466989004	Wheelchair, attendant/occupant-driven, front-wheels-operated, non-collapsible (physical object)
466999009	Wheelchair, electric-motor-driven, attendant-controlled, powered-steering, collapsible (physical object)
467018005	Wheelchair, occupant-driven, single-lever-operated, non-collapsible (physical object)
467065004	Wheelchair, occupant-driven, single-front-wheel-operated, collapsible (physical object)
467077009	Wheelchair, electric-motor-driven, attendant/occupant-controlled, manual-steering, non-collapsible (physical object)
467095007	Wheelchair, power-assisted, occupant-controlled, collapsible (physical object)
467137003	Wheelchair, occupant-driven, single-rear-wheel-operated, non-collapsible (physical object)
467155007	Walking chair, non-foldable (physical object)
467163008	Wheelchair, occupant-driven, single-front-wheel-operated, non-collapsible (physical object)
469361005	Heat/moisture exchanger, reusable (physical object)
469860004	All-plastic conventional wheelchair (physical object)
470119002	Heat/moisture exchanger, single-use (physical object)
470174002	Heat/moisture exchanger insertable filter (physical object)
58938008	Wheelchair device (physical object)
66435007	Electric bed, device (physical object)
700593005	Heated respiratory humidifier (physical object)
700705005	Non-heated respiratory humidifier (physical object)
700910000	Ultrasonic respiratory humidifier (physical object)
702172008	Home continuous positive airway pressure unit (physical object)
702173003	Home bilevel positive airway pressure unit (physical object)
705404007	Walker/Walking frame (physical object)
705406009	Walker (physical object)
705419008	Special-function wheelchair (physical object)
705421003	Sports wheelchair (physical object)
705422005	Power-driven wheelchair (physical object)
705423000	Electric-motor-driven wheelchair (physical object)
705425007	Attendant/occupant-controlled electric-motor-driven wheelchair (physical object)
705426008	Attendant-controlled electric-motor-driven wheelchair (physical object)
705427004	Power-assisted wheelchair (physical object)
705428009	Manual-driven wheelchair (physical object)
706180003	Respiratory humidifier (physical object)
714700001	Bilevel positive airway pressure unit hand held (physical object)
71545009	Household humidifier, device (physical object)
781471009	Gait rehabilitation electronic walker (physical object)
87405001	Cane, device (physical object)

Frailty Diagnosis

This is captured by adding a diagnosis with a valid ICD10 or SNOMED code using the Diagnosis widget in a note.

ICD-10:
L89.001	Pressure ulcer of unspecified elbow, stage 1
L89.002	Pressure ulcer of unspecified elbow, stage 2
L89.003	Pressure ulcer of unspecified elbow, stage 3
L89.004	Pressure ulcer of unspecified elbow, stage 4
L89.006	Pressure-induced deep tissue damage of unspecified elbow
L89.009	Pressure ulcer of unspecified elbow, unspecified stage
L89.010	Pressure ulcer of right elbow, unstageable
L89.011	Pressure ulcer of right elbow, stage 1
L89.012	Pressure ulcer of right elbow, stage 2
L89.013	Pressure ulcer of right elbow, stage 3
L89.014	Pressure ulcer of right elbow, stage 4
L89.016	Pressure-induced deep tissue damage of right elbow
L89.019	Pressure ulcer of right elbow, unspecified stage
L89.020	Pressure ulcer of left elbow, unstageable
L89.021	Pressure ulcer of left elbow, stage 1
L89.022	Pressure ulcer of left elbow, stage 2
L89.023	Pressure ulcer of left elbow, stage 3
L89.024	Pressure ulcer of left elbow, stage 4
L89.026	Pressure-induced deep tissue damage of left elbow
L89.029	Pressure ulcer of left elbow, unspecified stage
L89.100	Pressure ulcer of unspecified part of back, unstageable
L89.101	Pressure ulcer of unspecified part of back, stage 1
L89.102	Pressure ulcer of unspecified part of back, stage 2
L89.103	Pressure ulcer of unspecified part of back, stage 3
L89.104	Pressure ulcer of unspecified part of back, stage 4
L89.106	Pressure-induced deep tissue damage of unspecified part of back
L89.109	Pressure ulcer of unspecified part of back, unspecified stage
L89.110	Pressure ulcer of right upper back, unstageable
L89.111	Pressure ulcer of right upper back, stage 1
L89.112	Pressure ulcer of right upper back, stage 2
L89.113	Pressure ulcer of right upper back, stage 3
L89.114	Pressure ulcer of right upper back, stage 4
L89.116	Pressure-induced deep tissue damage of right upper back
L89.119	Pressure ulcer of right upper back, unspecified stage
L89.120	Pressure ulcer of left upper back, unstageable
L89.121	Pressure ulcer of left upper back, stage 1
L89.122	Pressure ulcer of left upper back, stage 2
L89.123	Pressure ulcer of left upper back, stage 3
L89.124	Pressure ulcer of left upper back, stage 4
L89.126	Pressure-induced deep tissue damage of left upper back
L89.129	Pressure ulcer of left upper back, unspecified stage
L89.130	Pressure ulcer of right lower back, unstageable
L89.131	Pressure ulcer of right lower back, stage 1
L89.132	Pressure ulcer of right lower back, stage 2
L89.133	Pressure ulcer of right lower back, stage 3
L89.134	Pressure ulcer of right lower back, stage 4
L89.136	Pressure-induced deep tissue damage of right lower back
L89.139	Pressure ulcer of right lower back, unspecified stage
L89.140	Pressure ulcer of left lower back, unstageable
L89.141	Pressure ulcer of left lower back, stage 1
L89.142	Pressure ulcer of left lower back, stage 2
L89.143	Pressure ulcer of left lower back, stage 3
L89.144	Pressure ulcer of left lower back, stage 4
L89.146	Pressure-induced deep tissue damage of left lower back
L89.149	Pressure ulcer of left lower back, unspecified stage
L89.150	Pressure ulcer of sacral region, unstageable
L89.151	Pressure ulcer of sacral region, stage 1
L89.152	Pressure ulcer of sacral region, stage 2
L89.153	Pressure ulcer of sacral region, stage 3
L89.154	Pressure ulcer of sacral region, stage 4
L89.156	Pressure-induced deep tissue damage of sacral region
L89.159	Pressure ulcer of sacral region, unspecified stage
L89.200	Pressure ulcer of unspecified hip, unstageable
L89.201	Pressure ulcer of unspecified hip, stage 1
L89.202	Pressure ulcer of unspecified hip, stage 2
L89.203	Pressure ulcer of unspecified hip, stage 3
L89.204	Pressure ulcer of unspecified hip, stage 4
L89.206	Pressure-induced deep tissue damage of unspecified hip
L89.209	Pressure ulcer of unspecified hip, unspecified stage
L89.210	Pressure ulcer of right hip, unstageable
L89.211	Pressure ulcer of right hip, stage 1
L89.212	Pressure ulcer of right hip, stage 2
L89.213	Pressure ulcer of right hip, stage 3
L89.214	Pressure ulcer of right hip, stage 4
L89.216	Pressure-induced deep tissue damage of right hip
L89.219	Pressure ulcer of right hip, unspecified stage
L89.220	Pressure ulcer of left hip, unstageable
L89.221	Pressure ulcer of left hip, stage 1
L89.222	Pressure ulcer of left hip, stage 2
L89.223	Pressure ulcer of left hip, stage 3
L89.224	Pressure ulcer of left hip, stage 4
L89.226	Pressure-induced deep tissue damage of left hip
L89.229	Pressure ulcer of left hip, unspecified stage
L89.300	Pressure ulcer of unspecified buttock, unstageable
L89.301	Pressure ulcer of unspecified buttock, stage 1
L89.302	Pressure ulcer of unspecified buttock, stage 2
L89.303	Pressure ulcer of unspecified buttock, stage 3
L89.304	Pressure ulcer of unspecified buttock, stage 4
L89.306	Pressure-induced deep tissue damage of unspecified buttock
L89.309	Pressure ulcer of unspecified buttock, unspecified stage
L89.310	Pressure ulcer of right buttock, unstageable
L89.311	Pressure ulcer of right buttock, stage 1
L89.312	Pressure ulcer of right buttock, stage 2
L89.313	Pressure ulcer of right buttock, stage 3
L89.314	Pressure ulcer of right buttock, stage 4
L89.316	Pressure-induced deep tissue damage of right buttock
L89.319	Pressure ulcer of right buttock, unspecified stage
L89.320	Pressure ulcer of left buttock, unstageable
L89.321	Pressure ulcer of left buttock, stage 1
L89.322	Pressure ulcer of left buttock, stage 2
L89.323	Pressure ulcer of left buttock, stage 3
L89.324	Pressure ulcer of left buttock, stage 4
L89.326	Pressure-induced deep tissue damage of left buttock
L89.329	Pressure ulcer of left buttock, unspecified stage
L89.40	Pressure ulcer of contiguous site of back, buttock and hip, unspecified stage
L89.41	Pressure ulcer of contiguous site of back, buttock and hip, stage 1
L89.42	Pressure ulcer of contiguous site of back, buttock and hip, stage 2
L89.43	Pressure ulcer of contiguous site of back, buttock and hip, stage 3
L89.44	Pressure ulcer of contiguous site of back, buttock and hip, stage 4
L89.45	Pressure ulcer of contiguous site of back, buttock and hip, unstageable
L89.46	Pressure-induced deep tissue damage of contiguous site of back, buttock and hip
L89.500	Pressure ulcer of unspecified ankle, unstageable
L89.501	Pressure ulcer of unspecified ankle, stage 1
L89.502	Pressure ulcer of unspecified ankle, stage 2
L89.503	Pressure ulcer of unspecified ankle, stage 3
L89.504	Pressure ulcer of unspecified ankle, stage 4
L89.506	Pressure-induced deep tissue damage of unspecified ankle
L89.509	Pressure ulcer of unspecified ankle, unspecified stage
L89.510	Pressure ulcer of right ankle, unstageable
L89.511	Pressure ulcer of right ankle, stage 1
L89.512	Pressure ulcer of right ankle, stage 2
L89.513	Pressure ulcer of right ankle, stage 3
L89.514	Pressure ulcer of right ankle, stage 4
L89.516	Pressure-induced deep tissue damage of right ankle
L89.519	Pressure ulcer of right ankle, unspecified stage
L89.520	Pressure ulcer of left ankle, unstageable
L89.521	Pressure ulcer of left ankle, stage 1
L89.522	Pressure ulcer of left ankle, stage 2
L89.523	Pressure ulcer of left ankle, stage 3
L89.524	Pressure ulcer of left ankle, stage 4
L89.526	Pressure-induced deep tissue damage of left ankle
L89.529	Pressure ulcer of left ankle, unspecified stage
L89.600	Pressure ulcer of unspecified heel, unstageable
L89.601	Pressure ulcer of unspecified heel, stage 1
L89.602	Pressure ulcer of unspecified heel, stage 2
L89.603	Pressure ulcer of unspecified heel, stage 3
L89.604	Pressure ulcer of unspecified heel, stage 4
L89.606	Pressure-induced deep tissue damage of unspecified heel
L89.609	Pressure ulcer of unspecified heel, unspecified stage
L89.610	Pressure ulcer of right heel, unstageable
L89.611	Pressure ulcer of right heel, stage 1
L89.612	Pressure ulcer of right heel, stage 2
L89.613	Pressure ulcer of right heel, stage 3
L89.614	Pressure ulcer of right heel, stage 4
L89.616	Pressure-induced deep tissue damage of right heel
L89.619	Pressure ulcer of right heel, unspecified stage
L89.620	Pressure ulcer of left heel, unstageable
L89.621	Pressure ulcer of left heel, stage 1
L89.622	Pressure ulcer of left heel, stage 2
L89.623	Pressure ulcer of left heel, stage 3
L89.624	Pressure ulcer of left heel, stage 4
L89.626	Pressure-induced deep tissue damage of left heel
L89.629	Pressure ulcer of left heel, unspecified stage
L89.810	Pressure ulcer of head, unstageable
L89.811	Pressure ulcer of head, stage 1
L89.812	Pressure ulcer of head, stage 2
L89.813	Pressure ulcer of head, stage 3
L89.814	Pressure ulcer of head, stage 4
L89.816	Pressure-induced deep tissue damage of head
L89.819	Pressure ulcer of head, unspecified stage
L89.890	Pressure ulcer of other site, unstageable
L89.891	Pressure ulcer of other site, stage 1
L89.892	Pressure ulcer of other site, stage 2
L89.893	Pressure ulcer of other site, stage 3
L89.894	Pressure ulcer of other site, stage 4
L89.896	Pressure-induced deep tissue damage of other site
L89.899	Pressure ulcer of other site, unspecified stage
L89.90	Pressure ulcer of unspecified site, unspecified stage
L89.91	Pressure ulcer of unspecified site, stage 1
L89.92	Pressure ulcer of unspecified site, stage 2
L89.93	Pressure ulcer of unspecified site, stage 3
L89.94	Pressure ulcer of unspecified site, stage 4
L89.95	Pressure ulcer of unspecified site, unstageable
L89.96	Pressure-induced deep tissue damage of unspecified site
M62.50	Muscle wasting and atrophy, not elsewhere classified, unspecified site
M62.81	Muscle weakness (generalized)
M62.84	Sarcopenia
W01.0XXA	Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter
W01.0XXD	Fall on same level from slipping, tripping and stumbling without subsequent striking against object, subsequent encounter
W01.0XXS	Fall on same level from slipping, tripping and stumbling without subsequent striking against object, sequela
W01.10XA	Fall on same level from slipping, tripping and stumbling with subsequent striking against unspecified object, initial encounter
W01.10XD	Fall on same level from slipping, tripping and stumbling with subsequent striking against unspecified object, subsequent encounter
W01.10XS	Fall on same level from slipping, tripping and stumbling with subsequent striking against unspecified object, sequela
W01.110A	Fall on same level from slipping, tripping and stumbling with subsequent striking against sharp glass, initial encounter
W01.110D	Fall on same level from slipping, tripping and stumbling with subsequent striking against sharp glass, subsequent encounter
W01.110S	Fall on same level from slipping, tripping and stumbling with subsequent striking against sharp glass, sequela
W01.111A	Fall on same level from slipping, tripping and stumbling with subsequent striking against power tool or machine, initial encounter
W01.111D	Fall on same level from slipping, tripping and stumbling with subsequent striking against power tool or machine, subsequent encounter
W01.111S	Fall on same level from slipping, tripping and stumbling with subsequent striking against power tool or machine, sequela
W01.118A	Fall on same level from slipping, tripping and stumbling with subsequent striking against other sharp object, initial encounter
W01.118D	Fall on same level from slipping, tripping and stumbling with subsequent striking against other sharp object, subsequent encounter
W01.118S	Fall on same level from slipping, tripping and stumbling with subsequent striking against other sharp object, sequela
W01.119A	Fall on same level from slipping, tripping and stumbling with subsequent striking against unspecified sharp object, initial encounter
W01.119D	Fall on same level from slipping, tripping and stumbling with subsequent striking against unspecified sharp object, subsequent encounter
W01.119S	Fall on same level from slipping, tripping and stumbling with subsequent striking against unspecified sharp object, sequela
W01.190A	Fall on same level from slipping, tripping and stumbling with subsequent striking against furniture, initial encounter
W01.190D	Fall on same level from slipping, tripping and stumbling with subsequent striking against furniture, subsequent encounter
W01.190S	Fall on same level from slipping, tripping and stumbling with subsequent striking against furniture, sequela
W01.198A	Fall on same level from slipping, tripping and stumbling with subsequent striking against other object, initial encounter
W01.198D	Fall on same level from slipping, tripping and stumbling with subsequent striking against other object, subsequent encounter
W01.198S	Fall on same level from slipping, tripping and stumbling with subsequent striking against other object, sequela
W06.XXXA	Fall from bed, initial encounter
W06.XXXD	Fall from bed, subsequent encounter
W06.XXXS	Fall from bed, sequela
W07.XXXA	Fall from chair, initial encounter
W07.XXXD	Fall from chair, subsequent encounter
W07.XXXS	Fall from chair, sequela
W08.XXXA	Fall from other furniture, initial encounter
W08.XXXD	Fall from other furniture, subsequent encounter
W08.XXXS	Fall from other furniture, sequela
W10.0XXA	Fall (on)(from) escalator, initial encounter
W10.0XXD	Fall (on)(from) escalator, subsequent encounter
W10.0XXS	Fall (on)(from) escalator, sequela
W10.1XXA	Fall (on)(from) sidewalk curb, initial encounter
W10.1XXD	Fall (on)(from) sidewalk curb, subsequent encounter
W10.1XXS	Fall (on)(from) sidewalk curb, sequela
W10.2XXA	Fall (on)(from) incline, initial encounter
W10.2XXD	Fall (on)(from) incline, subsequent encounter
W10.2XXS	Fall (on)(from) incline, sequela
W10.8XXA	Fall (on) (from) other stairs and steps, initial encounter
W10.8XXD	Fall (on) (from) other stairs and steps, subsequent encounter
W10.8XXS	Fall (on) (from) other stairs and steps, sequela
W10.9XXA	Fall (on) (from) unspecified stairs and steps, initial encounter
W10.9XXD	Fall (on) (from) unspecified stairs and steps, subsequent encounter
W10.9XXS	Fall (on) (from) unspecified stairs and steps, sequela
W18.00XA	Striking against unspecified object with subsequent fall, initial encounter
W18.00XD	Striking against unspecified object with subsequent fall, subsequent encounter
W18.00XS	Striking against unspecified object with subsequent fall, sequela
W18.02XA	Striking against glass with subsequent fall, initial encounter
W18.02XD	Striking against glass with subsequent fall, subsequent encounter
W18.02XS	Striking against glass with subsequent fall, sequela
W18.09XA	Striking against other object with subsequent fall, initial encounter
W18.09XD	Striking against other object with subsequent fall, subsequent encounter
W18.09XS	Striking against other object with subsequent fall, sequela
W18.11XA	Fall from or off toilet without subsequent striking against object, initial encounter
W18.11XD	Fall from or off toilet without subsequent striking against object, subsequent encounter
W18.11XS	Fall from or off toilet without subsequent striking against object, sequela
W18.12XA	Fall from or off toilet with subsequent striking against object, initial encounter
W18.12XD	Fall from or off toilet with subsequent striking against object, subsequent encounter
W18.12XS	Fall from or off toilet with subsequent striking against object, sequela
W18.2XXA	Fall in (into) shower or empty bathtub, initial encounter
W18.2XXD	Fall in (into) shower or empty bathtub, subsequent encounter
W18.2XXS	Fall in (into) shower or empty bathtub, sequela
W18.30XA	Fall on same level, unspecified, initial encounter
W18.30XD	Fall on same level, unspecified, subsequent encounter
W18.30XS	Fall on same level, unspecified, sequela
W18.31XA	Fall on same level due to stepping on an object, initial encounter
W18.31XD	Fall on same level due to stepping on an object, subsequent encounter
W18.31XS	Fall on same level due to stepping on an object, sequela
W18.39XA	Other fall on same level, initial encounter
W18.39XD	Other fall on same level, subsequent encounter
W18.39XS	Other fall on same level, sequela
W19.XXXA	Unspecified fall, initial encounter
W19.XXXD	Unspecified fall, subsequent encounter
W19.XXXS	Unspecified fall, sequela
Y92.199	Unspecified place in other specified residential institution as the place of occurrence of the external cause
Z59.3	Problems related to living in residential institution
Z73.6	Limitation of activities due to disability
Z74.01	Bed confinement status
Z74.09	Other reduced mobility
Z74.1	Need for assistance with personal care
Z74.2	Need for assistance at home and no other household member able to render care
Z74.3	Need for continuous supervision
Z74.8	Other problems related to care provider dependency
Z74.9	Problem related to care provider dependency, unspecified
Z91.81	History of falling
Z99.11	Dependence on respirator [ventilator] status
Z99.3	Dependence on wheelchair
Z99.81	Dependence on supplemental oxygen
Z99.89	Dependence on other enabling machines and devices

 

SNOMED:
10637031000119106	Pressure ulcer of buttock stage 1 (disorder)
10637071000119109	Pressure ulcer of buttock stage 2 (disorder)
10637111000119102	Pressure ulcer of buttock stage 3 (disorder)
10637151000119101	Pressure ulcer of buttock stage 4 (disorder)
129588001	Adult failure to thrive syndrome (disorder)
138371000119104	Paresis as late effect of poliomyelitis (disorder)
162845004	On examination – failure to thrive (disorder)
16728003	Inherited spastic paresis (disorder)
17886000	Fall from wheelchair (event)
20902002	Fall from bed (event)
214436006	Noncollision motor vehicle traffic accident involving fall down stairs of motor bus while boarding or alighting (event)
214437002	Noncollision motor vehicle traffic accident involving fall down stairs of motor bus while boarding or alighting, driver of motor vehicle injured (event)
214438007	Noncollision motor vehicle traffic accident involving fall down stairs of motor bus while boarding or alighting, passenger of motor vehicle injured (event)
214439004	Noncollision motor vehicle traffic accident involving fall down stairs of motor bus while boarding or alighting, motor cyclist injured (event)
214441003	Noncollision motor vehicle traffic accident involving fall down stairs of motor bus while boarding or alighting, occupant of tram injured (event)
214442005	Noncollision motor vehicle traffic accident involving fall down stairs of motor bus while boarding or alighting, rider of animal or occupant of animal-drawn vehicle injured (event)
214443000	Noncollision motor vehicle traffic accident involving fall down stairs of motor bus while boarding or alighting, pedal cyclist injured (event)
214444006	Noncollision motor vehicle traffic accident involving fall down stairs of motor bus while boarding or alighting, pedestrian injured (event)
217082002	Accidental fall (event)
217083007	Fall on or from stairs or steps (event)
217084001	Fall on or from escalator (event)
217086004	Fall from escalator (event)
217088003	Fall on or from stairs (event)
217090002	Fall from stairs (event)
217092005	Fall on or from steps (event)
217093000	Fall on steps (event)
217094006	Fall from steps (event)
217142006	Fall from chair or bed (event)
217154006	Fall on same level from slipping, tripping or stumbling (event)
217155007	Fall on same level from slipping (event)
217156008	Fall on same level from tripping (event)
217157004	Fall on same level from stumbling (event)
217158009	Fall on moving sidewalk (event)
217173005	Fall from bump against object (event)
225558004	Pressure ulcer of back (disorder)
225562005	Pressure ulcer of sacral region (disorder)
225563000	Pressure ulcer of buttock (disorder)
242109009	Fall down stairs of motor bus while boarding or alighting (event)
242389003	Fall due to wet surface (event)
242390007	Fall due to polished surface (event)
242391006	Fall due to discarded object (event)
242392004	Fall in bath or shower (event)
242395002	Fall due to trip on loose carpet (event)
242396001	Fall due to uneven surface indoors (event)
242413007	Fall from furniture (event)
242414001	Fall from stool (event)
242419006	Fall from toilet seat (event)
269699007	Fall on same level from impact against object (event)
274918000	Fall on same level due to nature of surface (event)
33036003	Fall on same level (event)
40104005	Fall in home (event)
414188008	Fall down stairs (event)
414189000	Fall down steps (event)
414190009	Fall on stairs (event)
427849003	Fall on hard surface (event)
428484005	Organic failure to thrive (disorder)
429621003	Fall on concrete (event)
44188002	Fall in shower (event)
459821000124104	McArdle sign (finding)
52702003	Chronic fatigue syndrome (disorder)
56307009	Fall from table (event)
67223001	Fall on escalator (event)
699214007	Pressure ulcer of hip (disorder)
699215008	Pressure ulcer of lower back (disorder)
699216009	Pressure ulcer of coccygeal region (disorder)
699218005	Pressure ulcer of upper back (disorder)
715504003	Spastic paraparesis co-occurrent with deafness (disorder)
74541001	Fall from bench (event)
763829004	Oculopharyngodistal myopathy (disorder)
823018004	Muscle paresis due to and following neuromuscular blockade (disorder)
83468000	Fall from chair (event)
8960001000004106	Pressure ulcer of skin of right ischial tuberosity region (disorder)
90619006	Fall in bathtub (event)
92341000119107	Weakness of extremities as sequela of stroke (disorder)

Frailty Encounter

This is captured by adding a procedure with a valid CPT/HCPCS or SNOMED code using the Procedure widget in a note.

CPT/HCPCS:
Code	Description
99504	Home visit for mechanical ventilation care
99509	Home visit for assistance with activities of daily living and personal care
G0162	Skilled services by a registered nurse (rn) for management and evaluation of the plan of care; each 15 minutes (the patient’s underlying condition or complication requires an rn to ensure that essential non-skilled care achieves its purpose in the home health or hospice setting)
G0299	Direct skilled nursing services of a registered nurse (rn) in the home health or hospice setting, each 15 minutes
G0300	Direct skilled nursing services of a licensed practical nurse (lpn) in the home health or hospice setting, each 15 minutes
G0493	Skilled services of a registered nurse (rn) for the observation and assessment of the patient’s condition, each 15 minutes (the change in the patient’s condition requires skilled nursing personnel to identify and evaluate the patient’s need for possible modification of treatment in the home health or hospice setting)
G0494	Skilled services of a licensed practical nurse (lpn) for the observation and assessment of the patient’s condition, each 15 minutes (the change in the patient’s condition requires skilled nursing personnel to identify and evaluate the patient’s need for possible modification of treatment in the home health or hospice setting)
S0271	Physician management of patient home care, hospice monthly case rate (per 30 days)
S0311	Comprehensive management and care coordination for advanced illness, per calendar month
S9123	Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when cpt codes 99500-99602 can be used)
S9124	Nursing care, in the home; by licensed practical nurse, per hour
T1000	Private duty / independent nursing service(s) – licensed, up to 15 minutes
T1001	Nursing assessment / evaluation
T1002	Rn services, up to 15 minutes
T1003	Lpn/lvn services, up to 15 minutes
T1004	Services of a qualified nursing aide, up to 15 minutes
T1005	Respite care services, up to 15 minutes
T1019	Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, icf/mr or imd, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant)
T1020	Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, icf/mr or imd, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant)
T1021	Home health aide or certified nurse assistant, per visit
T1022	Contracted home health agency services, all services provided under contract, per day
T1030	Nursing care, in the home, by registered nurse, per diem
T1031	Nursing care, in the home, by licensed practical nurse, per diem

Frailty Symptom

This is captured by adding a diagnosis with a valid ICD10 or SNOMED code using the Diagnosis widget in a note.

ICD-10:
Code	Description
R26.0	Ataxic gait
R26.1	Paralytic gait
R26.2	Difficulty in walking, not elsewhere classified
R26.89	Other abnormalities of gait and mobility
R26.9	Unspecified abnormalities of gait and mobility
R41.81	Age-related cognitive decline
R53.1	Weakness
R53.81	Other malaise
R53.83	Other fatigue
R54	Age-related physical debility
R62.7	Adult failure to thrive
R63.4	Abnormal weight loss
R63.6	Underweight
R64	Cachexia

 

SNOMED:
Code	Description
102492002	Failure to maintain weight (finding)
102568007	Paresis of lower extremity (finding)
102891000	Age-related cognitive decline (finding)
105501005	Dependence on enabling machine or device (finding)
105503008	Dependence on wheelchair (finding)
105504002	Dependence on walking stick (finding)
126013009	Subjective muscle weakness (finding)
127378008	Bilateral paresis (finding)
135834002	Pseudoparalysis (finding)
13791008	Asthenia (finding)
152921000119101	Dependence on respiratory device (finding)
15634971000119107	Weakness of bilateral upper limbs (finding)
16018391000119104	Paresis of left lower limb (finding)
16018431000119109	Paresis of right lower limb (finding)
160681005	Mobile outside with aid (finding)
160683008	Needs walking aid in home (finding)
160684002	Confined to chair (finding)
160685001	Bed-ridden (finding)
160692006	Mobility very poor (finding)
160693001	Mobility poor (finding)
160734000	Lives in a nursing home (finding)
160737007	Lives in an old peoples home (finding)
161832001	Weight decreasing (finding)
161873000	Heavy legs (finding)
161874006	Heavy feeling (finding)
162236007	Weakness present (finding)
162239000	Abdominal weakness (finding)
163600007	On examination – paresis (weakness) (finding)
163686004	On examination – gait ataxic (finding)
163695007	On examination – muscle power reduced (finding)
16419651000119103	Dependence on biphasic positive airway pressure ventilation due to central sleep apnea syndrome (finding)
165243005	Independent in wheelchair (finding)
165244004	Minimal help in wheelchair (finding)
18726006	Senile asthenia (finding)
20940004	Spinal hemiparesis (finding)
22090007	Scissoring gait (finding)
22325002	Abnormal gait (finding)
224960004	Tired (finding)
225612007	Wheelchair bound (finding)
22631008	Unsteady when walking (finding)
23042008	Spinal paraparesis (finding)
238108007	Cachexia (finding)
248269005	Tired on least exertion (finding)
248278004	Attacks of weakness (finding)
248279007	Frailty (finding)
249888000	Weakness of sternomastoid (finding)
249937002	Truncal muscle weakness (finding)
249938007	Weakness of back (finding)
249939004	Proximal muscle weakness (finding)
249940002	Shoulder girdle weakness (finding)
249941003	Pelvic girdle weakness (finding)
249942005	Distal muscle weakness (finding)
249943000	Weakness of distal arms and legs (finding)
249946008	Pyramidal type muscle weakness (finding)
250002000	Rapid fatigue of gait (finding)
250003005	Low level sensorimotor gait disorder (finding)
250015009	Arthritic gait (finding)
250029005	Sensory ataxic gait (finding)
250032008	Vestibular ataxic gait (finding)
250033003	Visual ataxic gait (finding)
250034009	Middle level sensorimotor gait disorder (finding)
250038007	Retropulsion when walking (finding)
250043000	High level sensorimotor gait disorder (finding)
250044006	Cautious gait (finding)
250045007	Tottering gait (finding)
250048009	Frontal ataxia (finding)
250052009	Petren’s gait (finding)
250054005	Frontal gait disorder (finding)
250991000119100	Stumbling gait (finding)
25136009	Ataxic gait (finding)
262285001	Weight decreased (finding)
26544005	Muscle weakness (finding)
267024001	Abnormal weight loss (finding)
267031002	Tiredness symptom (finding)
267032009	Tired all the time (finding)
268964003	On examination – festination-Parkinson gait (finding)
271795006	Malaise and fatigue (finding)
271875007	Senile debility (finding)
272036004	Complaining of debility and malaise (finding)
272060000	Fatigue – symptom (finding)
272062008	Complaining of “tired all the time” (finding)
275313006	Dragging leg (finding)
284529003	Cardiac cachexia (finding)
298283006	Hand muscle weakness (finding)
300948004	Quadriceps weakness (finding)
309249007	Calf muscle weakness (finding)
309257005	Excessive weight loss (finding)
312444006	Spastic paraparesis (finding)
314109004	Feeling tired (finding)
365884000	Cerebellar ataxic gait (finding)
367391008	Malaise (finding)
371028005	Spastic paresis (finding)
373931001	Sensation of heaviness in limbs (finding)
394616008	Unsteady gait (finding)
397776000	Festinating gait (finding)
404904002	Frail elderly (finding)
413121008	Dependent on helper pushing wheelchair (finding)
41786007	Neurological muscle weakness (finding)
418073009	Pseudoparalysis due to generalized arthritis (finding)
422868009	Unexplained weight loss (finding)
426977000	Recent weight loss (finding)
428116008	Multifactorial gait problem (finding)
428264009	Painful gait (finding)
429091008	Dependence on biphasic positive airway pressure ventilation (finding)
429487005	Dependence on continuous positive airway pressure ventilation (finding)
43005009	Shuffling gait (finding)
431524008	Abnormal gait due to impairment of balance (finding)
432559006	Abnormal gait due to muscle weakness (finding)
442099003	Psychogenic fatigue (finding)
444042007	Excessive postexertional fatigue (finding)
444932008	Dependence on ventilator (finding)
4468000	Oppenheim’s gait (finding)
448765001	Unintentional weight loss (finding)
459821000124104	McArdle sign (finding)
50314001	Partial bilateral paresis (finding)
60631000119109	Dependence on home ventilator (finding)
60651000119103	Dependence on continuous supplemental oxygen (finding)
67141003	Antalgic gait (finding)
69161000119103	Functional gait abnormality (finding)
713512009	Muscle weakness of upper limb (finding)
713514005	Muscle weakness of limb (finding)
713568000	Occasionally tired (finding)
713655003	Dependence on non-invasive ventilation (finding)
78119002	Complete bilateral paresis (finding)
784317004	Fatigue due to chemotherapy (finding)
784318009	Fatigue due to radiation therapy (finding)
78691002	Staggering gait (finding)
788876001	Cachexia due to malignant neoplastic disease (finding)
788900007	Dependence on artificial heart (finding)
79021000119104	Dependence on aspirator (finding)
79031000119101	Dependence on respirator (finding)
84229001	Fatigue (finding)
8510008	Reduced mobility (finding)
85711000119103	Stumbling due to lack of coordination (finding)
89201000119106	Dependence on supplemental oxygen when ambulating (finding)
89362005	Weight loss (finding)
931000119107	Dependence on supplemental oxygen (finding)