Files > V CPT

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.
.01cpt(+)0;1POINTER81BThis 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.
.02patient name(+)0;2POINTER9000001This is the patient to whom the procedure was done during the encounter.
.03visit(+)0;3POINTER9000010ADThis is the encounter or occasion of service defined in the Visit file that represents when and where the procedure was done.
.04provider narrative(+)0;4POINTER9999999.27This 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.
.05diagnosis0;5POINTER80This is the diagnosis, from the ICD Diagnosis file, associated with the procedure performed.
.07principal procedure0;7BOOLEANY:YES
This field identifies this procedure as the prinicipal procedure done to the patient at the encounter.
.09diagnosis 20;9POINTER80This is the diagnosis, from the ICD Diagnosis file, associated with the procedure performed.
.1diagnosis 30;10POINTER80This is the diagnosis, from the ICD Diagnosis file, associated with the procedure performed.
.11diagnosis 40;11POINTER80
.12diagnosis 50;12POINTER80
.13diagnosis 60;13POINTER80
.14diagnosis 70;14POINTER80
.15diagnosis 80;15POINTER80
.16quantity0;16NUMERICThis is the number of times this procedure was done to the patient during the encounter.
.17order reference0;17POINTER100Pointer to the order in the Order file (#100) that ordered the procedure.
.19department code0;19FREE TEXTThe 3-digit code that defines the service area associated with the charge by the sending application.
.2pfss charge id0;20NUMERICA 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.
1cpt modifier1;0MULTIPLE9000010.181
1201event date and time12;1DATE-TIMEThis 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.
1202ordering provider12;2POINTER200This field can be used to document the provider who ordered the procedure.
1204encounter provider12;4POINTER200This is the provider who performed the procedure.
80101edited flag801;1SET OF CODES1:EDITED
This field is automatically set to 1 if PCE detects that any original procedure data is being edited.
80102audit trail801;2FREE TEXTThis 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_";"...
80201provider narrative category802;1POINTER9999999.27This 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.
81101comments811;1FREE TEXTThis is a commented related to the procedure performed. The provider may enter this manually via the PCE User Interface.
81203data source812;3POINTER839.7

Not Referenced