@smarttracker/blue-button-generate
Version:
Blue Button CCDA Generator.
1,268 lines • 30.8 kB
JSON
{
"data": {
"demographics": {
"name": {
"first": "JOHN",
"last": "DOE"
},
"dob": {
"point": {
"date": "1910-01-01T00:00:00Z",
"precision": "day"
}
},
"email": [
{
"address": "JOHNDOE@example.com"
}
],
"phone": [
{
"number": "123-456-7890",
"type": "primary home"
}
],
"addresses": [
{
"use": "primary home",
"street_lines": [
"123 ANY ROAD"
],
"city": "ANYTOWN",
"state": "VA",
"zip": "00001",
"country": "US"
}
]
},
"vitals": [
{
"vital": {
"code": "8480-6",
"name": "Intravascular Systolic",
"code_system_name": "LOINC"
},
"date_time": {
"point": {
"date": "2011-07-22T15:00:00Z",
"precision": "hour"
}
},
"value": 120,
"unit": "mm[Hg]",
"status": "completed"
},
{
"vital": {
"code": "8462-4",
"name": "Intravascular Diastolic",
"code_system_name": "LOINC"
},
"date_time": {
"point": {
"date": "2011-07-22T15:00:00Z",
"precision": "hour"
}
},
"value": 80,
"unit": "mm[Hg]",
"status": "completed"
},
{
"vital": {
"name": "Glucose"
},
"date_time": {
"point": {
"date": "2012-03-20T12:00:00Z",
"precision": "hour"
}
},
"value": 110,
"unit": "mg/dL",
"status": "completed"
}
],
"results": [
{
"result_set": {
"name": "Glucose Level"
},
"results": [
{
"date_time": {
"point": {
"date": "2008-03-21T00:00:00Z",
"precision": "day"
}
},
"result": {
"name": "FBS"
},
"status": "completed",
"value": 135,
"unit": "mg/dL"
},
{
"date_time": {
"point": {
"date": "2008-03-21T00:00:00Z",
"precision": "day"
}
},
"result": {
"name": "RBS"
},
"status": "completed",
"value": 170,
"unit": "mg/dL"
},
{
"date_time": {
"point": {
"date": "2008-03-21T00:00:00Z",
"precision": "day"
}
},
"result": {
"name": "RBS"
},
"status": "completed",
"value": 150,
"unit": "mg/dL"
},
{
"date_time": {
"point": {
"date": "2008-03-21T00:00:00Z",
"precision": "day"
}
},
"result": {
"name": "RBS"
},
"status": "completed",
"value": 120,
"unit": "mg/dL"
}
]
}
],
"medications": [
{
"product": {
"product": {
"name": "Aspirin"
},
"unencoded_name": "Aspirin"
},
"sig": "Aspirin",
"status": "Completed"
}
],
"allergies": [
{
"observation": {
"allergen": {
"name": "Antibotic"
},
"date_time": {
"low": {
"date": "1926-01-08T00:00:00Z",
"precision": "day"
},
"high": {
"date": "1955-03-13T00:00:00Z",
"precision": "day"
}
},
"reactions": [
{
"reaction": {
"name": "Vomiting"
},
"severity": {
"code": {
"code": "24484000",
"name": "Severe",
"code_system_name": "SNOMED CT"
}
}
}
],
"status": {
"name": "Active",
"code": "55561003",
"code_system_name": "SNOMED CT"
}
}
},
{
"observation": {
"allergen": {
"name": "Grasses"
},
"date_time": {
"low": {
"date": "1973-05-13T00:00:00Z",
"precision": "day"
},
"high": {
"date": "1996-07-20T00:00:00Z",
"precision": "day"
}
},
"reactions": [
{
"reaction": {
"name": "Sneezing"
},
"severity": {
"code": {
"code": "24484000",
"name": "Severe",
"code_system_name": "SNOMED CT"
}
}
}
],
"status": {
"name": "Active",
"code": "55561003",
"code_system_name": "SNOMED CT"
}
}
}
],
"immunizations": [
{
"status": "complete",
"administration": {
"route": {
"name": "Nasal Spray(mist)"
}
},
"product": {
"product": {
"name": "Varicella/Chicken Pox"
}
},
"date_time": {
"point": {
"date": "2002-04-21T00:00:00Z",
"precision": "day"
}
}
},
{
"status": "complete",
"administration": {
"route": {
"name": "Nasal Spray(mist)"
}
},
"product": {
"product": {
"name": "Varicella/Chicken Pox (booster 1)"
}
},
"date_time": {
"point": {
"date": "1990-02-02T00:00:00Z",
"precision": "day"
}
}
},
{
"status": "complete",
"administration": {
"route": {
"name": "Injection"
}
},
"product": {
"product": {
"name": "typhoid"
}
},
"date_time": {
"point": {
"date": "2009-01-02T00:00:00Z",
"precision": "day"
}
}
}
],
"problems": [
{
"problem": {
"code": {
"name": "Arthritis"
}
},
"date_time": {
"low": {
"date": "2005-08-09T00:00:00Z",
"precision": "day"
},
"high": {
"date": "2011-02-28T00:00:00Z",
"precision": "day"
}
}
},
{
"problem": {
"code": {
"name": "Asthma"
}
},
"date_time": {
"low": {
"date": "2008-01-25T00:00:00Z",
"precision": "day"
},
"high": {
"date": "2010-01-25T00:00:00Z",
"precision": "day"
}
}
}
],
"payers": [
{
"participant": {
"performer": {
"identifiers": [
{
"identifier": "H9999/9999"
}
]
},
"date_time": {
"low": {
"date": "2011-09-01T00:00:00Z",
"precision": "day"
}
}
},
"policy_holder": {
"performer": {
"identifiers": [
{
"identifier": "H9999/9999"
}
]
}
},
"policy": {
"insurance": {
"performer": {
"organization": [
{
"name": [
"A Medicare Plan Plus (HMO)",
"HealthCare Payer",
"3 - Coordinated Care Plan (HMO, PPO, PSO, SNP)"
],
"address": [
{
"use": "primary home",
"street_lines": [
"123 Any Road"
],
"city": "Anytown",
"state": "PA",
"zip": "00003",
"country": "United States"
}
]
}
]
}
}
}
},
{
"participant": {
"performer": {
"identifiers": [
{
"identifier": "S9999/000"
}
]
},
"date_time": {
"low": {
"date": "2010-01-01T00:00:00Z",
"precision": "day"
}
}
},
"policy_holder": {
"performer": {
"identifiers": [
{
"identifier": "S9999/000"
}
]
}
},
"policy": {
"insurance": {
"performer": {
"organization": [
{
"name": [
"A Medicare Rx Plan (PDP)",
"Another HealthCare Payer",
"11 - Medicare Prescription Drug Plan"
],
"address": [
{
"use": "primary home",
"street_lines": [
"123 Any Road"
],
"city": "Anytown",
"state": "PA",
"zip": "00003",
"country": "United States"
}
]
}
]
}
}
}
},
{
"policy": {
"insurance": {
"performer": {
"organization": [
{
"name": [
"STATE HEALTH BENEFITS PROGRAM",
"EMPLOYER SUBSIDY"
]
}
]
}
}
},
"participant": {
"date_time": {
"low": {
"date": "2011-01-01T00:00:00Z",
"precision": "day"
},
"high": {
"date": "2011-12-31T00:00:00Z",
"precision": "day"
}
}
}
},
{
"participant": {
"performer": {
"identifiers": [
{
"identifier": "1234567890"
}
]
},
"date_time": {
"low": {
"date": "2011-01-01T00:00:00Z",
"precision": "day"
},
"high": {
"date": "2011-09-30T00:00:00Z",
"precision": "day"
}
}
},
"policy_holder": {
"performer": {
"identifiers": [
{
"identifier": "1234567890"
}
]
}
},
"policy": {
"insurance": {
"performer": {
"organization": [
{
"name": [
"Insurer1",
"Medicare MSP: End stage Renal Disease (ESRD)"
],
"address": [
{
"use": "primary home",
"street_lines": [
"PO BOX 0000"
],
"city": "Anytown",
"state": "CO",
"zip": "00002-0000",
"country": "United States"
}
]
}
]
}
}
}
},
{
"participant": {
"performer": {
"identifiers": [
{
"identifier": "12345678901"
}
]
},
"date_time": {
"low": {
"date": "2010-01-01T00:00:00Z",
"precision": "day"
},
"high": {
"date": "2010-12-31T00:00:00Z",
"precision": "day"
}
}
},
"policy_holder": {
"performer": {
"identifiers": [
{
"identifier": "12345678901"
}
]
}
},
"policy": {
"insurance": {
"performer": {
"organization": [
{
"name": [
"Insurer2",
"Medicare MSP: End stage Renal Disease (ESRD)"
],
"address": [
{
"use": "primary home",
"street_lines": [
"0000 Any ROAD"
],
"city": "ANYWHERE",
"state": "VA",
"zip": "00000-0000",
"country": "United States"
}
]
}
]
}
}
}
},
{
"participant": {
"performer": {
"identifiers": [
{
"identifier": "00001"
}
]
},
"date_time": {
"low": {
"date": "1984-10-01T00:00:00Z",
"precision": "day"
},
"high": {
"date": "2008-11-30T00:00:00Z",
"precision": "day"
}
}
},
"policy_holder": {
"performer": {
"identifiers": [
{
"identifier": "00001"
}
]
}
},
"policy": {
"insurance": {
"performer": {
"organization": [
{
"name": [
"Insurer"
],
"address": [
{
"use": "primary home",
"street_lines": [
"00 Address STREET"
],
"city": "ANYWHERE",
"state": "PA",
"zip": "00000",
"country": "United States"
}
]
}
]
}
}
}
}
],
"claims": [
{
"payer": [
"medicare"
],
"number": "1234567890000",
"date_time": {
"low": {
"date": "2012-10-18T00:00:00Z",
"precision": "day"
},
"high": {
"date": "2012-10-18T00:00:00Z",
"precision": "day"
}
},
"lines": [
{
"line": "1",
"date_time": {
"low": {
"date": "2012-10-18T00:00:00Z",
"precision": "day"
},
"high": {
"date": "2012-10-18T00:00:00Z",
"precision": "day"
}
},
"procedure": {
"code": "98941",
"description": "Chiropractic Manipulative Treatment (Cmt); Spinal, Three To Four Regions"
},
"quantity": {
"value": 1,
"unit": "line"
},
"modifier": [
{
"code": "AT",
"description": "Acute Treatment (This Modifier Should Be Used When Reporting Service 98940, 98941, 98942)"
}
],
"charges": {
"price_billed": "$60.00",
"insurance_paid": "$34.00",
"patient_responsibility": "$26.00"
},
"place_of_service": {
"code": "11",
"name": "Office"
},
"type": {
"code": "1",
"name": "Medical Care"
},
"performer": [
{
"type": "rendering provider",
"identifiers": [
{
"identifier": "2.16.840.1.113883.4.6",
"extension": "123456789"
}
]
}
]
}
],
"charges": {
"price_billed": "$60.00",
"insurance_paid": "$34.00",
"provider_paid": "$27.20",
"patient_responsibility": "$6.80"
},
"type": [
"medicare PartB"
],
"diagnosis": [
{
"code": "3534"
},
{
"code": "7393"
},
{
"code": "7392"
},
{
"code": "3533"
}
]
},
{
"payer": [
"medicare"
],
"number": "12345678900000VAA",
"date_time": {
"low": {
"date": "2012-09-22T00:00:00Z",
"precision": "day"
}
},
"lines": [
{
"line": "1",
"date_time": {
"low": {
"date": "2012-09-22T00:00:00Z",
"precision": "day"
}
},
"revenue": {
"code": "0250",
"description": "General Classification PHARMACY"
},
"quantity": {
"value": 1,
"unit": "line"
},
"charges": {
"price_billed": "$14.30",
"insurance_paid": "$14.30",
"patient_responsibility": "$0.00"
}
},
{
"line": "2",
"date_time": {
"low": {
"date": "2012-09-22T00:00:00Z",
"precision": "day"
}
},
"revenue": {
"code": "0320",
"description": "General Classification DX X"
},
"procedure": {
"code": "74020",
"description": "Radiologic Examination, Abdomen; Complete, Including Decubitus And/Or Erect Views"
},
"quantity": {
"value": 1,
"unit": "line"
},
"charges": {
"price_billed": "$175.50",
"insurance_paid": "$175.50",
"patient_responsibility": "$0.00"
}
},
{
"line": "3",
"date_time": {
"low": {
"date": "2012-09-22T00:00:00Z",
"precision": "day"
}
},
"revenue": {
"code": "0450",
"description": "General Classification EMERG ROOM"
},
"procedure": {
"code": "99283",
"description": "Emergency Department Visit For The Evaluation And Management Of A Patient, Which Requires Th"
},
"quantity": {
"value": 1,
"unit": "line"
},
"modifier": [
{
"code": "25",
"description": "Significant, Separately Identifiable Evaluation And Management Service By The Same Physician On"
}
],
"charges": {
"price_billed": "$315.00",
"insurance_paid": "$315.00",
"patient_responsibility": "$0.00"
}
},
{
"line": "4",
"revenue": {
"code": "0001",
"description": "Total Charges"
},
"quantity": {
"value": 0,
"unit": "line"
},
"charges": {
"price_billed": "$504.80",
"insurance_paid": "$504.80",
"patient_responsibility": "$0.00"
}
}
],
"charges": {
"price_billed": "$504.80",
"insurance_paid": "$504.80",
"provider_paid": "$126.31",
"patient_responsibility": "$38.84"
},
"type": [
"medicare Outpatient"
],
"diagnosis": [
{
"code": "56400"
},
{
"code": "7245"
},
{
"code": "V1588"
}
]
},
{
"payer": [
"medicare"
],
"number": "1234567890123",
"lines": [
{
"line": "1",
"date_time": {
"low": {
"date": "2012-12-01T00:00:00Z",
"precision": "day"
},
"high": {
"date": "2012-12-01T00:00:00Z",
"precision": "day"
}
},
"procedure": {
"code": "98941",
"description": "Chiropractic Manipulative Treatment, 3 To 4 Spinal Regions"
},
"quantity": {
"value": 1,
"unit": "line"
},
"modifier": [
{
"code": "GA",
"description": "Waiver Of Liability Statement Issued As Required By Payer Policy, Individual Case"
}
],
"place_of_service": {
"code": "11",
"name": "Office"
},
"type": {
"code": "1",
"name": "Medical Care"
},
"performer": [
{
"type": "rendering provider",
"identifiers": [
{
"identifier": "2.16.840.1.113883.4.6",
"extension": "123456789"
}
]
}
]
},
{
"line": "2",
"date_time": {
"low": {
"date": "2012-12-01T00:00:00Z",
"precision": "day"
},
"high": {
"date": "2012-12-01T00:00:00Z",
"precision": "day"
}
},
"procedure": {
"code": "G0283",
"description": "Electrical Stimulation (Unattended), To One Or More Areas For Indication(S) Other Than Wound"
},
"quantity": {
"value": 1,
"unit": "line"
},
"modifier": [
{
"code": "GY",
"description": "Item Or Service Statutorily Excluded, Does Not Meet The Definition Of Any Medicare Benefit Or,"
}
],
"place_of_service": {
"code": "11",
"name": "Office"
},
"type": {
"code": "1",
"name": "Medical Care"
},
"performer": [
{
"type": "rendering provider",
"identifiers": [
{
"identifier": "2.16.840.1.113883.4.6",
"extension": "123456789"
}
]
}
]
}
],
"date_time": {
"low": {
"date": "2012-12-01T00:00:00Z",
"precision": "day"
},
"high": {
"date": "2012-12-01T00:00:00Z",
"precision": "day"
}
}
},
{
"payer": [
"medicare"
],
"number": "123456789012",
"date_time": {
"point": {
"date": "2011-11-17T00:00:00Z",
"precision": "day"
}
},
"type": [
"medicare Part D"
],
"lines": [
{
"date_time": {
"point": {
"date": "2011-11-17T00:00:00Z",
"precision": "day"
}
},
"drug": {
"code": "00093013505",
"name": "CARVEDILOL"
},
"performer": [
{
"identifiers": [
{
"identifier": "2.16.840.1.113883.4.6",
"extension": "123456789"
}
],
"type": "prescriber",
"name": [
{
"first": "Jane",
"last": "Doe"
}
]
},
{
"type": "pharmacy",
"identifiers": [
{
"identifier": "2.16.840.1.113883.4.6",
"extension": "123456789"
}
],
"name": [
"PHARMACY2 #00000"
]
}
]
}
],
"performer": [
{
"identifiers": [
{
"identifier": "2.16.840.1.113883.4.6",
"extension": "123456789"
}
],
"type": "prescriber",
"name": [
{
"first": "Jane",
"last": "Doe"
}
]
},
{
"type": "pharmacy",
"identifiers": [
{
"identifier": "2.16.840.1.113883.4.6",
"extension": "123456789"
}
],
"name": [
"PHARMACY2 #00000"
]
}
]
},
{
"payer": [
"medicare"
],
"number": "123456789011",
"date_time": {
"point": {
"date": "2011-11-23T00:00:00Z",
"precision": "day"
}
},
"type": [
"medicare Part D"
],
"lines": [
{
"date_time": {
"point": {
"date": "2011-11-23T00:00:00Z",
"precision": "day"
}
},
"drug": {
"code": "00781223310",
"name": "OMEPRAZOLE"
},
"performer": [
{
"identifiers": [
{
"identifier": "2.16.840.1.113883.4.6",
"extension": "123456789"
}
],
"type": "prescriber",
"name": [
{
"first": "Jane",
"last": "Doe"
}
]
},
{
"type": "pharmacy",
"identifiers": [
{
"identifier": "2.16.840.1.113883.4.6",
"extension": "1234567890"
}
],
"name": [
"PHARMACY3 #00000"
]
}
]
}
],
"performer": [
{
"identifiers": [
{
"identifier": "2.16.840.1.113883.4.6",
"extension": "123456789"
}
],
"type": "prescriber",
"name": [
{
"first": "Jane",
"last": "Doe"
}
]
},
{
"type": "pharmacy",
"identifiers": [
{
"identifier": "2.16.840.1.113883.4.6",
"extension": "1234567890"
}
],
"name": [
"PHARMACY3 #00000"
]
}
]
}
],
"plan_of_care": [
{
"plan": {
"name": "DIABETES"
},
"type": "medicare",
"date_time": {
"low": {
"date": "2011-10-01T00:00:00Z",
"precision": "day"
}
}
},
{
"plan": {
"name": "PAP TEST DR"
},
"type": "medicare",
"date_time": {
"low": {
"date": "2011-10-01T00:00:00Z",
"precision": "day"
}
}
},
{
"plan": {
"name": "ABDOMINAL AORTIC ANEURYSM"
},
"type": "medicare",
"date_time": {
"low": {
"date": "2012-07-01T00:00:00Z",
"precision": "day"
}
}
},
{
"plan": {
"name": "ANNUAL WELLNESS VISIT"
},
"type": "medicare",
"date_time": {
"low": {
"date": "2013-01-01T00:00:00Z",
"precision": "day"
}
}
},
{
"plan": {
"name": "DEPRESSION SCREENING"
},
"type": "medicare",
"date_time": {
"low": {
"date": "2012-10-14T00:00:00Z",
"precision": "day"
}
}
}
],
"providers": [
{
"address": {
"use": "primary home",
"street_lines": [
"123 Any Rd"
],
"city": "Anywhere",
"state": "MD",
"zip": "99999",
"country": "United States"
},
"type": {
"name": "NHC"
},
"organization": {
"name": [
"ANY CARE"
]
}
},
{
"name": {
"first": "Jane",
"last": "Doe"
},
"address": {
"use": "primary home",
"street_lines": [
"123 Road"
],
"city": "Anywhere",
"state": "VA",
"zip": "00001",
"country": "United States"
},
"type": {
"name": "PHY"
}
}
]
},
"meta": {
"type": "cms",
"version": "2.0",
"timestamp": {
"date": "2013-03-16T05:10:00Z",
"precision": "minute"
},
"sections": [
"demographics",
"vitals",
"results",
"medications",
"allergies",
"immunizations",
"problems",
"payers",
"claims",
"plan_of_care",
"providers"
]
}
}