German Practice Management FHIR Profiles (R4)
0.71.0 - STU1 DE

German Practice Management FHIR Profiles (R4) - Local Development build (v0.71.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Claim Diagnosis Contract

Claim Diagnosis Contract

This page defines the quarter diagnosis contract for Praxis Claim profiles. The primary carrier is PraxisPreliminaryBillingClaimDE, because it carries the quarterly billing context and service items. Final claims may echo the same diagnosis list when needed for downstream submission or audit.

Carrier

Claim.diagnosis carries quarterly treatment diagnoses (Behandlungsdiagnosen). Each entry should use diagnosisReference to reference the source PraxisCondition that contributed the billing diagnosis. When no Condition resource is available, diagnosisCodeableConcept may carry the ICD-10-GM coding directly.

Source Conditions are retained as clinical documentation. They are never deleted or destructively merged just because a billing tuple collapses for Claim output. Rule predicates, such as "any confirmed diabetes diagnosis in the quarter", are derived from the source Conditions.

Billing Tuple

The uniqueness key for Claim.diagnosis is the exact billing tuple:

Tuple part Source
ICD code Condition.code.coding using ICD-10-GM
Diagnosesicherheit http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit
Seitenlokalisation http://fhir.de/StructureDefinition/seitenlokalisation
Mehrfachcodierungskennzeichen http://fhir.de/StructureDefinition/icd-10-gm-mehrfachcodierungs-kennzeichen

Only exact tuple duplicates may collapse in the Claim diagnosis list. A naked ICD code is not a valid deduplication key. For example, the same ICD with G and V, or with R and L, produces separate Claim.diagnosis entries. There is no generic G > V > Z > A precedence rule.

Diagnosesicherheit Resolution

The KBV-AWS diagnosis certainty semantics resolve to Condition status as follows:

Diagnosesicherheit Meaning Condition.verificationStatus Condition.clinicalStatus
G gesichert confirmed active
V Verdacht provisional or differential active
Z Zustand nach confirmed resolved
A ausgeschlossen refuted not required

Z means resolved or state-after for the specific diagnosis tuple. It is not a generic long-term diagnosis marker. The Dauerdiagnose concept (permanent/long-term diagnosis flag used in some PVS systems) is handled separately and must not be inferred from Z.

Implementation Contract

Downstream resolution logic must:

  • Preserve source Conditions.
  • Build the Claim diagnosis list from exact billing tuples.
  • Keep different Diagnosesicherheit, laterality, and multiple-coding marker values as separate Claim diagnosis entries.
  • Collapse only exact tuple duplicates when producing the Claim projection.
  • Preserve Seitenlokalisation and Mehrfachcodierungskennzeichen on the source ICD coding and, when using diagnosisCodeableConcept, on the Claim diagnosis coding.
  • ADR-005: docs/adr/ADR-005-account-centered-billing-case-model.md
  • AW-SST crosswalk: input/pagecontent/aw-sst-crosswalk.md
  • fpde-cj3: AccountPraxisSchein and EncounterPraxis contact re-scope
  • fpde-mub: this Claim.diagnosis contract and KBV-AWS diagnosis certainty mapping
  • External bead 59tj / ADR-039: downstream Account-centered billing-case decision