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
I11.0	Hypertensive heart disease with heart failure
I13.0	Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I13.2	Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease
I50.1	Left ventricular failure, unspecified
I50.20	Unspecified systolic (congestive) heart failure
I50.21	Acute systolic (congestive) heart failure
I50.22	Chronic systolic (congestive) heart failure
I50.23	Acute on chronic systolic (congestive) heart failure
I50.30	Unspecified diastolic (congestive) heart failure
I50.31	Acute diastolic (congestive) heart failure
I50.32	Chronic diastolic (congestive) heart failure
I50.33	Acute on chronic diastolic (congestive) heart failure
I50.40	Unspecified combined systolic (congestive) and diastolic (congestive) heart failure
I50.41	Acute combined systolic (congestive) and diastolic (congestive) heart failure
I50.42	Chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.43	Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.814	Right heart failure due to left heart failure
I50.82	Biventricular heart failure
I50.83	High output heart failure
I50.84	End stage heart failure
I50.89	Other heart failure
I50.9	Heart failure, unspecified

 

SNOMED:
Code	Description
10091002	High output heart failure (disorder)
101281000119107	Congestive heart failure due to cardiomyopathy (disorder)
10633002	Acute congestive heart failure (disorder)
111283005	Chronic left-sided heart failure (disorder)
120851000119104	Systolic heart failure stage D (disorder)
120861000119102	Systolic heart failure stage C (disorder)
120871000119108	Systolic heart failure stage B (disorder)
120881000119106	Diastolic heart failure stage D (disorder)
120891000119109	Diastolic heart failure stage C (disorder)
120901000119108	Diastolic heart failure stage B (disorder)
153931000119109	Acute combined systolic and diastolic heart failure (disorder)
153941000119100	Chronic combined systolic and diastolic heart failure (disorder)
153951000119103	Acute on chronic combined systolic and diastolic heart failure (disorder)
15629541000119106	Congestive heart failure stage C due to Ischemic cardiomyopathy (disorder)
15629591000119103	Congestive heart failure stage B due to ischemic cardiomyopathy (disorder)
15629641000119107	Systolic heart failure stage B due to ischemic cardiomyopathy (disorder)
15629741000119102	Systolic heart failure stage C due to ischemic cardiomyopathy (disorder)
15781000119107	Hypertensive heart AND chronic kidney disease with congestive heart failure (disorder)
15964701000119109	Acute cor pulmonale co-occurrent and due to saddle embolus of pulmonary artery (disorder)
194767001	Benign hypertensive heart disease with congestive cardiac failure (disorder)
194779001	Hypertensive heart and renal disease with (congestive) heart failure (disorder)
194781004	Hypertensive heart and renal disease with both (congestive) heart failure and renal failure (disorder)
195111005	Decompensated cardiac failure (disorder)
195112003	Compensated cardiac failure (disorder)
195125002	Acute left ventricular failure (disorder)
206586757	Congenital cardiac failure (disorder)
23341000119109	Congestive heart failure with right heart failure (disorder)
233924009	Heart failure as a complication of care (disorder)
25544003	Low output heart failure (disorder)
314206753	Refractory heart failure (disorder)
364006	Acute left-sided heart failure (disorder)
410431009	Cardiorespiratory failure (disorder)
417996759	Systolic heart failure (disorder)
418304008	Diastolic heart failure (disorder)
42343007	Congestive heart failure (disorder)
424404003	Decompensated chronic heart failure (disorder)
426263006	Congestive heart failure due to left ventricular systolic dysfunction (disorder)
426611007	Congestive heart failure due to valvular disease (disorder)
43736758	Rheumatic left ventricular failure (disorder)
44088000	Low cardiac output syndrome (disorder)
441481004	Chronic systolic heart failure (disorder)
441530006	Chronic diastolic heart failure (disorder)
44313006	Right heart failure secondary to left heart failure (disorder)
443253003	Acute on chronic systolic heart failure (disorder)
443254009	Acute systolic heart failure (disorder)
443343001	Acute diastolic heart failure (disorder)
443344007	Acute on chronic diastolic heart failure (disorder)
46113002	Hypertensive heart failure (disorder)
471880001	Heart failure due to end stage congenital heart disease (disorder)
48447003	Chronic heart failure (disorder)
5148006	Hypertensive heart disease with congestive heart failure (disorder)
5375005	Chronic left-sided congestive heart failure (disorder)
56675007	Acute heart failure (disorder)
67431000119105	Congestive heart failure stage D (disorder)
67441000119101	Congestive heart failure stage C (disorder)
698594003	Symptomatic congestive heart failure (disorder)
703272007	Heart failure with reduced ejection fraction (disorder)
703273002	Heart failure with reduced ejection fraction due to coronary artery disease (disorder)
703274008	Heart failure with reduced ejection fraction due to myocarditis (disorder)
703275009	Heart failure with reduced ejection fraction due to cardiomyopathy (disorder)
703276755	Heart failure with reduced ejection fraction due to heart valve disease (disorder)
717840005	Congestive heart failure stage B (disorder)
72481000119103	Congestive heart failure as early postoperative complication (disorder)
74967503	Acute left-sided congestive heart failure (disorder)
82523003	Congestive rheumatic heart failure (disorder)
83105008	Malignant hypertensive heart disease with congestive heart failure (disorder)
84125007	Heart failure (disorder)
85232009	Left heart failure (disorder)
88805009	Chronic congestive heart failure (disorder)
90727007	Pleural effusion due to congestive heart failure (disorder)
92506755	Biventricular congestive heart failure (disorder)

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

CPT:
Code	Description
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.
99304	Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or 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 problem(s) requiring admission are of low severity. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit.
99305	Initial nursing facility care, per day, for the evaluation and management of a 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 problem(s) requiring admission are of moderate severity. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit.
99306	Initial nursing facility care, per day, for the evaluation and management of a 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 problem(s) requiring admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient’s facility floor or unit.
99307	Subsequent nursing facility care, per day, for the evaluation and management of a 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 patient is stable, recovering, or improving. Typically, 10 minutes are spent at the bedside and on the patient’s facility floor or unit.
99308	Subsequent nursing facility care, per day, for the evaluation and management of a 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 patient is responding inadequately to therapy or has developed a minor complication. Typically, 15 minutes are spent at the bedside and on the patient’s facility floor or unit.
99309	Subsequent nursing facility care, per day, for the evaluation and management of a 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 patient has developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit.
99310	Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive interval 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. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit.
99315	Nursing facility discharge day management; 30 minutes or less
99316	Nursing facility discharge day management; more than 30 minutes
99318	Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: A detailed interval history; A comprehensive examination; and Medical decision making that is of low to 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 patient is stable, recovering, or improving. Typically, 30 minutes are spent at the bedside and on the patient’s facility floor or unit.
99324	Domiciliary or rest 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 with the patient and/or family or caregiver.
99325	Domiciliary or rest 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 with the patient and/or family or caregiver.
99326	Domiciliary or rest 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 with the patient and/or family or caregiver.
99327	Domiciliary or rest 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 with the patient and/or family or caregiver.
99328	Domiciliary or rest 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 with the patient and/or family or caregiver.
99334	Domiciliary or rest 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 with the patient and/or family or caregiver.
99335	Domiciliary or rest 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 with the patient and/or family or caregiver.
99336	Domiciliary or rest 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 of moderate to high severity. Typically, 40 minutes are spent with the patient and/or family or caregiver.
99337	Domiciliary or rest 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 with the patient and/or family or caregiver.
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.

 

SNOMED:
Code	Description
18170008	Subsequent nursing facility visit (procedure)
185316007	Indirect encounter (procedure)
185317003	Telephone encounter (procedure)
185318008	Third party encounter (procedure)
185320006	Encounter by computer link (procedure)
185321005	Letter encounter to patient (procedure)
185349003	Encounter for check up (procedure)
185460008	Home visit request by patient (procedure)
185462000	Home visit request by relative (procedure)
185463005	Visit out of hours (procedure)
185464004	Out of hours visit – not night visit (procedure)
185465003	Weekend visit (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)
207195004	History and physical examination with evaluation and management of nursing facility patient (procedure)
209099002	History and physical examination with management of domiciliary or rest home patient (procedure)
210098006	Domiciliary or rest home patient evaluation and management (procedure)
225929007	Joint home visit (procedure)
270424005	Letter encounter from patient (procedure)
270427003	Patient-initiated encounter (procedure)
270430005	Provider-initiated encounter (procedure)
281036007	Follow-up consultation (procedure)
30346009	Evaluation and management of established outpatient in office or other outpatient facility (procedure)
308335008	Patient encounter procedure (procedure)
308720009	Letter encounter (procedure)
315205008	Bank holiday home visit (procedure)
3391000175108	Office visit for pediatric care and assessment (procedure)
37894004	Evaluation and management of new outpatient in office or other outpatient facility (procedure)
386473003	Telephone follow-up (procedure)
390906007	Follow-up encounter (procedure)
401267002	Telephone triage encounter (procedure)
401271004	E-mail sent to patient (procedure)
406547006	Urgent follow-up (procedure)
438515009	E-mail encounter from carer (procedure)
438516005	E-mail encounter to carer (procedure)
439708006	Home visit (procedure)
439740005	Postoperative follow-up visit (procedure)
445450000	Encounter by short message service text messaging (procedure)
448337001	Telemedicine consultation with patient (procedure)
698704008	Home visit for rheumatology service (procedure)
704126008	Home visit for anticoagulant drug monitoring (procedure)
77406008	Confirmatory medical consultation (procedure)
87790002	Follow-up inpatient consultation visit (procedure)
90526000	Initial evaluation and management of healthy individual (procedure)

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

CPT:
Code	Description
99238	Hospital discharge day management; 30 minutes or less.
99239	Hospital discharge day management; more than 30 minutes.

This is captured by adding a numeric result with a valid LOINC code using a numeric control in a note.

LOINC:
Code	Description
10230-1	Left ventricular Ejection fraction
18043-0	Left ventricular Ejection fraction by US
18044-8	Left ventricular Ejection fraction by US.2D+Calculated by single-plane ellipse method
18045-5	Left ventricular Ejection fraction by US.2D+Calculated by biplane ellipse method
18046-3	Left ventricular Ejection fraction by US 2D modified
18047-1	Left ventricular Ejection fraction by US 2D modified biplane
18048-9	Left ventricular Ejection fraction by US 2D modified single-plane
18049-7	Left ventricular Ejection fraction by US.M-mode+Calculated by Teichholz method
77889-4	Left ventricular Ejection fraction by US.M-mode+Calculated by cube method
77890-2	Left ventricular Ejection fraction by US.2D+Calculated by cube method
77891-0	Left ventricular Ejection fraction by US.2D+Calculated by Teichholz method
77892-8	Left ventricular Ejection fraction by US.2D+Calculated by modified Simpson method
79990-8	Left ventricular Ejection fraction by US.3D.segmentation
79991-6	Left ventricular Ejection fraction by US.2D+Calculated by biplane method of disks
79992-4	Left ventricular Ejection fraction by US.2D.A2C+Calculated by single plane method of disks
79993-2	Left ventricular Ejection fraction by US.2D.A4C+Calculated by single plane method of disks
8806-2	Left ventricular Ejection fraction by 2D echo
8807-0	Left ventricular Ejection fraction by 2D echo.visual estimate
8808-8	Left ventricular Ejection fraction by Cardiac angiogram
8809-6	Left ventricular Ejection fraction by Cardiac angiogram.visual estimate
8810-4	Left ventricular Ejection fraction by Spiral CT
8811-2	Left ventricular Ejection fraction by MR
8812-0	Left ventricular Ejection fraction by Nuclear blood pool

SNOMED:
Code	Description
981000124106	Moderate left ventricular systolic dysfunction (disorder)
991000124109	Severe left ventricular systolic dysfunction (disorder)

SNOMED:
Code	Description
134401001	Left ventricular systolic dysfunction (disorder)
6736007	Moderate (severity modifier) (qualifier value)
24484000	Severe (severity modifier) (qualifier value)

• A medication allergy to an ingredient of beta blocker therapy  is captured by entering a medication ingredient with a valid RXNORM code in the Allergy widget in a note.

OR
• A medication intolerance to beta blocker therapy  is captured by discontinuing a beta blocker therapy medication with a valid RXNORM code and selecting a reason of intolerance using the medication button in a note or the facesheet in a chart.

Allergy:

RXNORM:
Code	Description
10600	Timolol
1202	Atenolol
149	Acebutolol
1520	Betaxolol
19484	Bisoprolol
20352	carvedilol
2116	Carteolol
6185	Labetalol
6918	Metoprolol
7226	Nadolol
8332	Pindolol
8787	Propranolol

Medication Intolerance:

RXNORM:
Code	Description
1191185	Penbutolol Sulfate 20 MG Oral Tablet
1297753	Betaxolol Hydrochloride 10 MG Oral Tablet
1297757	Betaxolol Hydrochloride 20 MG Oral Tablet
1495058	Propranolol Hydrochloride 4.28 MG/ML Oral Solution
152916	Atenolol 50 MG / Chlorthalidone 12.5 MG Oral Tablet
1593725	Sotalol Hydrochloride 5 MG/ML Oral Solution
1923422	Sotalol Hydrochloride 120 MG Oral Tablet
1923424	Sotalol Hydrochloride 160 MG Oral Tablet
1923426	Sotalol Hydrochloride 80 MG Oral Tablet
197379	Atenolol 100 MG Oral Tablet
197380	Atenolol 25 MG Oral Tablet
197381	Atenolol 50 MG Oral Tablet
197382	Atenolol 100 MG / Chlorthalidone 25 MG Oral Tablet
197383	Atenolol 50 MG / Chlorthalidone 25 MG Oral Tablet
198000	Bendroflumethiazide 5 MG / Nadolol 40 MG Oral Tablet
198001	Bendroflumethiazide 5 MG / Nadolol 80 MG Oral Tablet
198006	Nadolol 20 MG Oral Tablet
198007	Nadolol 40 MG Oral Tablet
198008	Nadolol 80 MG Oral Tablet
198104	Pindolol 10 MG Oral Tablet
198105	Pindolol 5 MG Oral Tablet
198284	Timolol 10 MG Oral Tablet
198285	Timolol 20 MG Oral Tablet
198286	Timolol 5 MG Oral Tablet
199277	Pindolol 15 MG Oral Tablet
199494	Oxprenolol 20 MG Oral Tablet
199495	Oxprenolol 40 MG Oral Tablet
199717	Clopamide 5 MG / Pindolol 10 MG Oral Tablet
199786	Oxprenolol 80 MG Oral Tablet
199787	Oxprenolol 160 MG Extended Release Oral Tablet
200031	carvedilol 6.25 MG Oral Tablet
200032	carvedilol 12.5 MG Oral Tablet
200033	carvedilol 25 MG Oral Tablet
245854	Hydrochlorothiazide 25 MG / Pindolol 10 MG Oral Tablet
245855	Hydrochlorothiazide 50 MG / Pindolol 10 MG Oral Tablet
387013	nebivolol 5 MG Oral Tablet
686924	carvedilol 3.125 MG Oral Tablet
751612	nebivolol 10 MG Oral Tablet
751618	nebivolol 2.5 MG Oral Tablet
827073	nebivolol 20 MG Oral Tablet
854901	Bisoprolol Fumarate 10 MG Oral Tablet
854905	Bisoprolol Fumarate 5 MG Oral Tablet
854908	Bisoprolol Fumarate 10 MG / Hydrochlorothiazide 6.25 MG Oral Tablet
854916	Bisoprolol Fumarate 2.5 MG / Hydrochlorothiazide 6.25 MG Oral Tablet
854919	Bisoprolol Fumarate 5 MG / Hydrochlorothiazide 6.25 MG Oral Tablet
856422	Hydrochlorothiazide 25 MG / Propranolol Hydrochloride 40 MG Oral Tablet
856429	Hydrochlorothiazide 25 MG / Propranolol Hydrochloride 80 MG Oral Tablet
856448	Propranolol Hydrochloride 10 MG Oral Tablet
856457	Propranolol Hydrochloride 20 MG Oral Tablet
856460	24 HR Propranolol Hydrochloride 120 MG Extended Release Oral Capsule
856481	24 HR Propranolol Hydrochloride 160 MG Extended Release Oral Capsule
856519	Propranolol Hydrochloride 40 MG Oral Tablet
856535	24 HR Propranolol Hydrochloride 60 MG Extended Release Oral Capsule
856556	Propranolol Hydrochloride 60 MG Oral Tablet
856569	24 HR Propranolol Hydrochloride 80 MG Extended Release Oral Capsule
856578	Propranolol Hydrochloride 80 MG Oral Tablet
856713	Propranolol Hydrochloride 160 MG Oral Tablet
856724	Propranolol Hydrochloride 4 MG/ML Oral Solution
856733	Propranolol Hydrochloride 8 MG/ML Oral Solution
860510	24 HR carvedilol phosphate 10 MG Extended Release Oral Capsule
860516	24 HR carvedilol phosphate 20 MG Extended Release Oral Capsule
860522	24 HR carvedilol phosphate 40 MG Extended Release Oral Capsule
860532	24 HR carvedilol phosphate 80 MG Extended Release Oral Capsule
866412	24 HR metoprolol succinate 100 MG Extended Release Oral Tablet
866419	24 HR metoprolol succinate 200 MG Extended Release Oral Tablet
866427	24 HR metoprolol succinate 25 MG Extended Release Oral Tablet
866436	24 HR metoprolol succinate 50 MG Extended Release Oral Tablet
866452	24 HR Hydrochlorothiazide 12.5 MG / metoprolol succinate 100 MG Extended Release Oral Tablet
866461	24 HR Hydrochlorothiazide 12.5 MG / metoprolol succinate 25 MG Extended Release Oral Tablet
866472	24 HR Hydrochlorothiazide 12.5 MG / metoprolol succinate 50 MG Extended Release Oral Tablet
866479	Hydrochlorothiazide 25 MG / Metoprolol Tartrate 100 MG Oral Tablet
866482	Hydrochlorothiazide 25 MG / Metoprolol Tartrate 50 MG Oral Tablet
866491	Hydrochlorothiazide 50 MG / Metoprolol Tartrate 100 MG Oral Tablet
866511	Metoprolol Tartrate 100 MG Oral Tablet
866514	Metoprolol Tartrate 50 MG Oral Tablet
866924	Metoprolol Tartrate 25 MG Oral Tablet
896758	Labetalol hydrochloride 100 MG Oral Tablet
896762	Labetalol hydrochloride 200 MG Oral Tablet
896766	Labetalol hydrochloride 300 MG Oral Tablet
896983	Labetalol hydrochloride 400 MG Oral Tablet
896987	Labetalol hydrochloride 50 MG Oral Tablet
904561	Sotalol Hydrochloride 100 MG Oral Tablet
904589	Sotalol Hydrochloride 240 MG Oral Tablet
998685	Acebutolol Hydrochloride 400 MG Oral Capsule
998689	Acebutolol Hydrochloride 200 MG Oral Capsule
998693	Acebutolol Hydrochloride 100 MG Oral Capsule
998694	Acebutolol Hydrochloride 200 MG / Hydrochlorothiazide 12.5 MG Oral Tablet
998695	Acebutolol Hydrochloride 400 MG Oral Tablet

This is captured by adding a diagnosis with a valid ICD10 and/or SNOMED code using the diagnosis widget in a note. (Applies to the following: An active diagnosis of allergy to beta blocker therapy, intolerance to beta blocker therapy, arrhythmia, hypotension, asthma, or bradycardia.)

Valid Diagnosis Codes for Arrhythmia Exception:

ICD-10:
Code	Description
I49.8	Other specified cardiac arrhythmias
I49.9	Cardiac arrhythmia, unspecified
SNOMED:
Code	Description
184004	Withdrawal arrhythmia (disorder)
10164001	Parasystole (disorder)
10626002	Multifocal premature ventricular complexes (disorder)
11157007	Ventricular bigeminy (disorder)
11849007	Atrioventricular junctional rhythm (disorder)
13640000	Fusion beats (disorder)
17338001	Ventricular premature beats (disorder)
17366009	Atrial arrhythmia (disorder)
17869006	Anomalous atrioventricular excitation (disorder)
26950008	Chronic ectopic atrial tachycardia (disorder)
27337007	Unifocal premature ventricular complexes (disorder)
29320008	Ectopic rhythm (disorder)
33413000	Ectopic beats (disorder)
36083008	Sick sinus syndrome (disorder)
38274001	Interpolated ventricular premature complexes (disorder)
39260000	Nonparoxysmal atrioventricular nodal tachycardia (disorder)
39357005	Paroxysmal atrial tachycardia with block (disorder)
40593004	Fibrillation (disorder)
44808001	Conduction disorder of the heart (disorder)
47830009	Junctional escape beats (disorder)
49982000	Multifocal atrial tachycardia (disorder)
55475008	Lown-Ganong-Levine syndrome (disorder)
59272004	Ventricular parasystole (disorder)
60423000	Sinus node dysfunction (disorder)
61277005	Accelerated idioventricular rhythm (disorder)
63232000	Multifocal premature beats (disorder)
63593006	Supraventricular premature beats (disorder)
69730002	Idiojunctional tachycardia (disorder)
71908006	Ventricular fibrillation (disorder)
72654001	Supraventricular arrhythmia (disorder)
74390002	Wolff-Parkinson-White pattern (disorder)
74615001	Tachycardia-bradycardia (disorder)
75532003	Ventricular escape beat (disorder)
81681009	Junctional premature beats (disorder)
81898007	Ventricular escape rhythm (disorder)
88412007	Atrio-ventricular node arrhythmia (disorder)
195060002	Ventricular pre-excitation (disorder)
195069001	Paroxysmal atrial tachycardia (disorder)
195071001	Paroxysmal junctional tachycardia (disorder)
195072008	Paroxysmal nodal tachycardia (disorder)
195083004	Ventricular fibrillation and flutter (disorder)
233891009	Sinoatrial node tachycardia (disorder)
233892002	Ectopic atrial tachycardia (disorder)
233893007	Re-entrant atrial tachycardia (disorder)
233894001	Incessant atrial tachycardia (disorder)
233895000	Ectopic atrioventricular node tachycardia (disorder)
233904005	Permanent junctional reciprocating tachycardia (disorder)
233915000	Paroxysmal familial ventricular fibrillation (disorder)
233922008	Concealed accessory pathway (disorder)
233923003	Unidirectional retrograde accessory pathway (disorder)
234172002	Electromechanical dissociation (disorder)
251161003	Slow ventricular response (disorder)
251162005	Atrio-ventricular-junctional (nodal) bradycardia (disorder)
251163000	Atrio-ventricular junctional (nodal) arrest (disorder)
251164006	Junctional premature complex (disorder)
251165007	Atrioventricular junctional (nodal) tachycardia (disorder)
251166008	Atrioventricular nodal re-entry tachycardia (disorder)
251167004	Aberrant premature complexes (disorder)
251168009	Supraventricular bigeminy (disorder)
251170000	Blocked premature atrial contraction (disorder)
251172008	Run of atrial premature complexes (disorder)
251173003	Atrial bigeminy (disorder)
251174009	Atrial trigeminy (disorder)
251175005	Ventricular premature complex (disorder)
251176006	Multiple premature ventricular complexes (disorder)
251177002	Run of ventricular premature complexes (disorder)
251178007	Ventricular interpolated complexes (disorder)
251179004	Multiple ventricular interpolated complexes (disorder)
251180001	Ventricular trigeminy (disorder)
251181002	Ventricular quadrigeminy (disorder)
251182009	Paired ventricular premature complexes (disorder)
251186007	Ventricular escape complex (disorder)
251187003	Atrial escape complex (disorder)
251188008	Atrial parasystole (disorder)
276796006	Atrial tachycardia (disorder)
284470004	Premature atrial contraction (disorder)
287057009	Atrial premature complex (disorder)
309809007	Electromechanical dissociation with successful resuscitation (disorder)
406461004	Ectopic atrial beats (disorder)
418341009	Atrioventricular conduction disorder (disorder)
418818005	Brugada syndrome (disorder)
419752005	Sinoatrial nodal reentrant tachycardia (disorder)
421869004	Bradyarrhythmia (disorder)
422348008	Andersen Tawil syndrome (disorder)
429243003	Sustained ventricular fibrillation (disorder)

Valid Diagnosis Codes for Hypotension Exception:

ICD-10:
Code	Description
I95.0	Idiopathic hypotension
I95.1	Orthostatic hypotension
I95.2	Hypotension due to drugs
I95.3	Hypotension of hemodialysis
I95.81	Postprocedural hypotension
I95.89	Other hypotension
I95.9	Hypotension, unspecified
SNOMED:
Code	Description
45007003	Low blood pressure (disorder)
61933008	Hyperadrenergic postural hypotension (disorder)
70247006	Hypoadrenergic postural hypotension (disorder)
75181005	Chronic orthostatic hypotension (disorder)
77545000	Chronic hypotension (disorder)
88887003	Maternal hypotension syndrome (disorder)
195506001	Idiopathic hypotension (disorder)
200113008	Maternal hypotension syndrome with antenatal problem (disorder)
200114002	Maternal hypotension syndrome with postnatal problem (disorder)
230664009	Sympathotonic orthostatic hypotension (disorder)
234171009	Drug-induced hypotension (disorder)
271870002	Low blood pressure reading (disorder)
286963007	Chronic hypotension – idiopathic (disorder)
371073003	Postural orthostatic tachycardia syndrome (disorder)
408667000	Hemodialysis-associated hypotension (disorder)
408668005	Iatrogenic hypotension (disorder)
429561008	Exertional hypotension (disorder)

Valid Diagnosis Codes for Asthma Exception:

ICD-10:
Code	Description
J45.20	Mild intermittent asthma, uncomplicated
J45.21	Mild intermittent asthma with (acute) exacerbation
J45.22	Mild intermittent asthma with status asthmaticus
J45.30	Mild persistent asthma, uncomplicated
J45.31	Mild persistent asthma with (acute) exacerbation
J45.32	Mild persistent asthma with status asthmaticus
J45.40	Moderate persistent asthma, uncomplicated
J45.41	Moderate persistent asthma with (acute) exacerbation
J45.42	Moderate persistent asthma with status asthmaticus
J45.50	Severe persistent asthma, uncomplicated
J45.51	Severe persistent asthma with (acute) exacerbation
J45.52	Severe persistent asthma with status asthmaticus
J45.901	Unspecified asthma with (acute) exacerbation
J45.902	Unspecified asthma with status asthmaticus
J45.909	Unspecified asthma, uncomplicated
J45.990	Exercise induced bronchospasm
J45.991	Cough variant asthma
J45.998	Other asthma

SNOMED:
Code	Description
11641008	Millers’ asthma (disorder)
12428000	Intrinsic asthma without status asthmaticus (disorder)
13151001	Flax-dressers’ disease (disorder)
195949008	Chronic asthmatic bronchitis (disorder)
195967001	Asthma (disorder)
195977004	Mixed asthma (disorder)
225057002	Brittle asthma (disorder)
233672007	Byssinosis grade 3 (disorder)
233678006	Childhood asthma (disorder)
233679003	Late onset asthma (disorder)
233683003	Hay fever with asthma (disorder)
233688007	Sulfite-induced asthma (disorder)
266361008	Non-allergic asthma (disorder)
281239006	Exacerbation of asthma (disorder)
304527002	Acute asthma (disorder)
31387002	Exercise-induced asthma (disorder)
370218001	Mild asthma (disorder)
370219009	Moderate asthma (disorder)
370220003	Occasional asthma (disorder)
370221004	Severe asthma (disorder)
389145006	Allergic asthma (disorder)
405944004	Asthmatic bronchitis (disorder)
407674008	Aspirin-induced asthma (disorder)
409663006	Cough variant asthma (disorder)
423889005	Non-immunoglobulin E mediated allergic asthma (disorder)
424199006	Substance induced asthma (disorder)
424643009	Immunoglobulin E-mediated allergic asthma (disorder)
425969006	Exacerbation of intermittent asthma (disorder)
426656000	Severe persistent asthma (disorder)
426979002	Mild persistent asthma (disorder)
427295004	Moderate persistent asthma (disorder)
427603009	Intermittent asthma (disorder)
427679007	Mild intermittent asthma (disorder)
442025000	Acute exacerbation of chronic asthmatic bronchitis (disorder)
55570000	Asthma without status asthmaticus (disorder)
56968009	Wood asthma (disorder)
59786004	Weavers’ cough (disorder)
63088003	Extrinsic asthma without status asthmaticus (disorder)
707445000	Exacerbation of mild persistent asthma (disorder)
707446004	Exacerbation of moderate persistent asthma (disorder)
707447008	Exacerbation of severe persistent asthma (disorder)
708038006	Acute exacerbation of asthma (disorder)
708090002	Acute severe exacerbation of asthma (disorder)
708093000	Acute exacerbation of immunoglobulin E-mediated allergic asthma (disorder)
708094006	Acute exacerbation of intrinsic asthma (disorder)
708095007	Acute severe exacerbation of immunoglobin E-mediated allergic asthma (disorder)
708096008	Acute severe exacerbation of intrinsic asthma (disorder)
782520007	Exacerbation of allergic asthma due to infection (disorder)
85761009	Byssinosis (disorder)
92807009	Chemical-induced asthma (disorder)
93432008	Drug-induced asthma (disorder)

Valid Beta Blocker Therapy Allergy Exclusion Codes:

SNOMED:
Code	Description
293962009	Beta-adrenoceptor blocking drug allergy (disorder)
293963004	Cardioselective beta-blocker allergy (disorder)
293964005	Acebutolol allergy (disorder)
293965006	Atenolol allergy (disorder)
293966007	Betaxolol allergy (disorder)
293967003	Bisoprolol allergy (disorder)
293968008	Celiprolol allergy (disorder)
293969000	Esmolol allergy (disorder)
293970004	Metoprolol allergy (disorder)
293971000	Non-cardioselective beta-blocker allergy (disorder)
293972007	Nadolol allergy (disorder)
293973002	Pindolol allergy (disorder)
293974008	Carvedilol allergy (disorder)
293975009	Metipranolol allergy (disorder)
293976005	Carteolol allergy (disorder)
293977001	Labetalol allergy (disorder)
293978006	Levobunolol allergy (disorder)
293979003	Oxprenolol allergy (disorder)
293980000	Penbutolol allergy (disorder)
293981001	Practolol allergy (disorder)
293982008	Propranolol allergy (disorder)
293983003	Sotalol allergy (disorder)
293984009	Timolol allergy (disorder)

Valid Beta Blocker Therapy Intolerance Exclusion Codes:

SNOMED:
Code	Description
292419005	Beta-adrenoceptor blocking drug adverse reaction (disorder)
292420004	Cardioselective beta-blocker adverse reaction (disorder)
292421000	Acebutolol adverse reaction (disorder)
292424008	Betaxolol adverse reaction (disorder)
292425009	Bisoprolol adverse reaction (disorder)
292426005	Celiprolol adverse reaction (disorder)
292427001	Esmolol adverse reaction (disorder)
292428006	Metoprolol adverse reaction (disorder)
292430008	Nadolol adverse reaction (disorder)
292431007	Pindolol adverse reaction (disorder)
292432000	Carvedilol adverse reaction (disorder)
292433005	Metipranolol adverse reaction (disorder)
292434004	Carteolol adverse reaction (disorder)
292435003	Labetalol adverse reaction (disorder)
292436002	Levobunolol adverse reaction (disorder)
292437006	Oxprenolol adverse reaction (disorder)
292438001	Penbutolol adverse reaction (disorder)
292439009	Practolol adverse reaction (disorder)
292440006	Propranolol adverse reaction (disorder)
292441005	Sotalol adverse reaction (disorder)
292442003	Timolol adverse reaction (disorder)
418370000	Atenolol adverse reaction (disorder)

Valid Diagnosis Codes for Bradycardia Exception:

ICD-10:
Code	Description
I49.5	Sick sinus syndrome
I49.8	Other specified cardiac arrhythmias
R00.1	Bradycardia, unspecified
SNOMED:
Code	Description
29894000	Vagal autonomic bradycardia (disorder)
44602002	Persistent sinus bradycardia (disorder)
49044005	Severe sinus bradycardia (disorder)
49710005	Sinus bradycardia (disorder)
251162005	Atrio-ventricular-junctional (nodal) bradycardia (disorder)
397841007	Drug-induced bradycardia (disorder)

Valid Diagnosis Codes for Atrioventricular Block Exception:

This can be captured in the following ways:

• Adding a diagnosis of cardiac pacer in situ with a valid ICD10 and/or SNOMED code using the diagnosis widget in a note.

OR

• Adding a procedure for implanting a cardiac pacer with a valid SNOMED code using the procedure widget in a note.

ICD-10:
Code	Description
I44.1	Atrioventricular block, second degree
I44.2	Atrioventricular block, complete
SNOMED:
Code	Description
27885002	Complete atrioventricular block (disorder)
28189009	Mobitz type II atrioventricular block (disorder)
54016002	Mobitz type I incomplete atrioventricular block (disorder)
93130009	Lenegre’s disease (disorder)
195042002	Second degree atrioventricular block (disorder)
233917008	Atrioventricular block (disorder)
233918003	Postoperative complete heart block (disorder)
251114004	Intermittent second degree atrioventricular block (disorder)
283645003	Lev’s syndrome (disorder)

Valid Diagnosis Codes for Cardiac Pacer that will negate the Atrioventricular Block Exception:

ICD-10:
Code	Description
Z95.0	Presence of cardiac pacemaker
SNOMED:
Code	Description
14106009	Cardiac pacemaker, device (physical object)
56961003	Cardiac transvenous pacemaker, device (physical object)
360127006	Intravenous cardiac pacemaker system (physical object)
360128001	Intravenous triggered cardiac pacemaker system (physical object)
424921004	Permanent cardiac pacemaker, device (physical object)
441509002	Cardiac pacemaker in situ (finding)

Entered via the Medication button in the note for the first encounter of the measurement period for the patient. 

• This is captured by adding a medication not ordered with a valid RXNORM code and attaching a valid SNOMED code for the reason not done using the medication button in a note.

Medical Reason

SNOMED:
Code	Description
183932001	Procedure contraindicated (situation)
183964008	Treatment not indicated (situation)
183966005	Drug treatment not indicated (situation)
266721009	Absent response to treatment (situation)
269191009	Late effect of medical and surgical care complication (disorder)
31438003	Drug resistance (disorder)
35688006	Complication of medical care (disorder)
397745006	Medical contraindication (finding)
407563006	Treatment not tolerated (situation)
410534003	Not indicated (qualifier value)
410536001	Contraindicated (qualifier value)
416098002	Allergy to drug (finding)
428119001	Procedure not indicated (situation)
59037007	Intolerance to drug (finding)
62014003	Adverse reaction caused by drug (disorder)
79899007	Drug interaction (finding)

Patient Reason

SNOMED	Description
105480006	Refusal of treatment by patient (situation)
134397009	Angiotensin converting enzyme inhibitor declined (situation)
401084003	Angioensin II receptor antagonist declined (situation)
160932005	Financial problem (finding)
160934006	Financial circumstances change (finding)
182890002	Patient requests alternative treatment (finding)
182895007	Drug declined by patient (situation)
182897004	Drug declined by patient – side effects (situation)
182900006	Drug declined by patient – patient beliefs (situation)
182902003	Medication declined by patient – cannot pay script (situation)
183944003	Procedure refused (situation)
183945002	Procedure refused for religious reason (situation)
184081006	Patient has moved away (finding)
185479006	Patient dissatisfied with result (finding)
185481008	Dissatisfied with doctor (finding)
224187001	Variable income (finding)
225928004	Patient self-discharge against medical advice (procedure)
713247000	Procedure discontinued by patient (situation)
266710000	Drugs not taken/completed (situation)
266966009	Family illness (situation)
275694009	Patient defaulted from follow-up (finding)
275936005	Patient noncompliance – general (situation)
281399006	Did not attend (finding)
310343007	Further opinion sought (finding)
373787003	Treatment delay – patient choice (finding)
406149000	Medication refused (situation)
408367005	Patient forgets to take medication (finding)
413310006	Patient non-compliant – refused access to services (situation)
413311005	Patient non-compliant – refused intervention / support (situation)
413312003	Patient non-compliant – refused service (situation)
416432009	Procedure discontinued by patient (situation)
423656007	Income insufficient to buy necessities (finding)
424739004	Income sufficient to buy only necessities (finding)
443390004	Refused (qualifier value)

System Reason

SNOMED	Description
107724000	Patient transfer (procedure)
182856006	Drug not available – out of stock (finding)
182857002	Drug not available-off market (finding)
185335007	Appointment canceled by hospital (finding)
224194003	Not entitled to benefits (finding)
224198000	Delay in receiving benefits (finding)
224199008	Loss of benefits (finding)
242990004	Drug not available for administration (event)
266756008	Medical care unavailable (situation)
270459005	Patient on waiting list (finding)
309017000	Referred to doctor (finding)
309846006	Treatment not available (situation)
419808006	Finding related to health insurance issues (finding)
424553001	Uninsured medical expenses (finding)

This is captured by prescribing or renewing a medication with a valid RXNORM code using the medication button in a note or the facesheet in a chart.

RXNORM:
Code	Description
200031	carvedilol 6.25 MG Oral Tablet
200032	carvedilol 12.5 MG Oral Tablet
200033	carvedilol 25 MG Oral Tablet
686924	carvedilol 3.125 MG Oral Tablet
854901	Bisoprolol Fumarate 10 MG Oral Tablet
854905	Bisoprolol Fumarate 5 MG Oral Tablet
854908	Bisoprolol Fumarate 10 MG / Hydrochlorothiazide 6.25 MG Oral Tablet
854916	Bisoprolol Fumarate 2.5 MG / Hydrochlorothiazide 6.25 MG Oral Tablet
854919	Bisoprolol Fumarate 5 MG / Hydrochlorothiazide 6.25 MG Oral Tablet
860510	24 HR carvedilol phosphate 10 MG Extended Release Oral Capsule
860516	24 HR carvedilol phosphate 20 MG Extended Release Oral Capsule
860522	24 HR carvedilol phosphate 40 MG Extended Release Oral Capsule
860532	24 HR carvedilol phosphate 80 MG Extended Release Oral Capsule
866412	24 HR metoprolol succinate 100 MG Extended Release Oral Tablet
866419	24 HR metoprolol succinate 200 MG Extended Release Oral Tablet
866427	24 HR metoprolol succinate 25 MG Extended Release Oral Tablet
866436	24 HR metoprolol succinate 50 MG Extended Release Oral Tablet
866452	24 HR Hydrochlorothiazide 12.5 MG / metoprolol succinate 100 MG Extended Release Oral Tablet
866461	24 HR Hydrochlorothiazide 12.5 MG / metoprolol succinate 25 MG Extended Release Oral Tablet
866472	24 HR Hydrochlorothiazide 12.5 MG / metoprolol succinate 50 MG Extended Release Oral Tablet