Files > V CPT

name

V CPT

number

9000010.18

location

^AUPNVCPT(

description

The V CPT file has been defined for joint use by the Indian Health Service and the Department of Veteran Affairs. This is the file used to store CPT related services performed at a visit. Data must exist for a patient and a visit before data can be entered in the V CPT file. This file is used in the VA to identify procedures that were done to a patient at an encounter or occassion of service. The procedures may have been performed by a primary or secondary provider of patient care. Procedures checked off and scanned from ambulatory care encounter forms are stored here to record that they were done. Results of procedures are not included. This file is restricted to procedures that have a CPT code. The V Treatment file is used to store procedures without CPT codes that do not fit into any other V-file category. The Provider Narrative field represents the preferred text for this procedure as defined by the clinician.

Fields

#	Name	Location	Type	Details	Index	Description
.01	cpt(+)	0;1	POINTER	81	B	This is the entry in the CPT file that most closely represents the clinical procedure done to the patient during the encounter. The preferred text for the procedure performed may be specified in the Provider Narrative field. This field is used for Administrative and Clinical purposes. If a procedure performed is to be billable, the CPT code must be specified here.
.02	patient name(+)	0;2	POINTER	9000001		This is the patient to whom the procedure was done during the encounter.
.03	visit(+)	0;3	POINTER	9000010	AD	This is the encounter or occasion of service defined in the Visit file that represents when and where the procedure was done.
.04	provider narrative(+)	0;4	POINTER	9999999.27		This is the narrative the provider uses to represent the procedure that was done. The text may be different from the CPT file's procedure name text, but should not have a significantly different meaning. The CPT code in the CPT (.01) field should be the CPT code that "most closely" represents the provider narrative for the procedure done.
.05	diagnosis	0;5	POINTER	80		This is the diagnosis, from the ICD Diagnosis file, associated with the procedure performed.
.07	principal procedure	0;7	BOOLEAN	Y:YES N:NO		This field identifies this procedure as the prinicipal procedure done to the patient at the encounter.
.09	diagnosis 2	0;9	POINTER	80		This is the diagnosis, from the ICD Diagnosis file, associated with the procedure performed.
.1	diagnosis 3	0;10	POINTER	80		This is the diagnosis, from the ICD Diagnosis file, associated with the procedure performed.
.11	diagnosis 4	0;11	POINTER	80
.12	diagnosis 5	0;12	POINTER	80
.13	diagnosis 6	0;13	POINTER	80
.14	diagnosis 7	0;14	POINTER	80
.15	diagnosis 8	0;15	POINTER	80
.16	quantity	0;16	NUMERIC			This is the number of times this procedure was done to the patient during the encounter.
.17	order reference	0;17	POINTER	100		Pointer to the order in the Order file (#100) that ordered the procedure.
.19	department code	0;19	FREE TEXT			The 3-digit code that defines the service area associated with the charge by the sending application.
.2	pfss charge id	0;20	NUMERIC			A numeric identifier of not more than 8 digits that uniquely identifies the charge item in the external medical billing system. This data item is referred to as the "PFSS Charge Identifier" within the PFSS project documentation.
1	cpt modifier	1;0	MULTIPLE	9000010.181
1201	event date and time	12;1	DATE-TIME			This is the date and time the procedure was performed. This date and time may be different from the visit data and time. For example, for clinic appointment visits, the visit date and time is the date and time of the appointment, not the time the provder performed the clinical event. The date may be an imprecise date. Date and time may be within 30 days before or after the visit date, with the restriction the date cannot be a future date.
1202	ordering provider	12;2	POINTER	200		This field can be used to document the provider who ordered the procedure.
1204	encounter provider	12;4	POINTER	200		This is the provider who performed the procedure.
80101	edited flag	801;1	SET OF CODES	1:EDITED		This field is automatically set to 1 if PCE detects that any original procedure data is being edited.
80102	audit trail	801;2	FREE TEXT			This field is populated automatically by the PCE filing logic.. The format of the field is as follows: Pointer to PCE data source file_"-"_A for Add or E for Edit_" "_DUZ of the person who entered the data_";"...
80201	provider narrative category	802;1	POINTER	9999999.27		This field is the heading or category used to represent the provider narrative on the scanner form. It may be useful for understanding how providers are grouping data for use on the encounter form, and may help determine clinical data base definitions in the future.
81101	comments	811;1	FREE TEXT			This is a commented related to the procedure performed. The provider may enter this manually via the PCE User Interface.
81201	verified	812;1	SET OF CODES	1:ELECTRONICALLY SIGNED 2:VERIFIED BY PACKAGE
81202	package	812;2	POINTER	9.4
81203	data source	812;3	POINTER	839.7