RE: ICD9 Procedure Codes vs HCPCS Procedure Codes

[Gregory . H . Krause]

Jim,   I believe that according to the final rule you may only use ICD9 procedure codes for inpatient procedures.  From page 50325 of the preamble: Comment: Two commenters stated that the proposal did not reflect current uses of some code sets. One commenter stated that in addition to being used for inpatient procedural coding, the ICD–9– CM procedure codes are also required by many health plans for the reporting of facility-based outpatient procedures. The second commenter pointed out that in addition to being used by physicians and other health care professionals, the combination of HCPCS level I and CPT– 4 is required for reporting ancillary services such as radiology and laboratory services and by some health plans for reporting facility-based procedures. Further, Medicare currently requires HCPCS level II codes for reporting services in skilled nursing facilities. Response: Health plans must conform to the requirements for code set use set out in this final rule. Therefore, if a health plan currently requires health care providers to use CPT–4 to report inpatient facility-based procedures, they both would be required to convert to ICD–9. We agree that the proposal did not reflect all current uses of some code sets. For example, we agree that CPT– 4 is commonly used to code laboratory tests, yet laboratory tests are not necessarily considered to be physician services. Moreover, the proposed rule implied that laboratory tests are a type of other health care service which are encoded using HCPCS. We believe that the architecture of both coding sets, HCPCS and CPT–4, is such that they are both frequently used for coding physician and other health care services. Both of these medical data code sets are standard medical data code sets and may be used in standard transactions (see � 162.1002(e)). Therefore, a health plan using CPT–4 to report outpatient facility-based procedures would not be required to change that practice. In addition, the proposed rule did not itemize the types of services included in other health care services. These other health care services include the ancillary services, radiology and laboratory which are mentioned in the comment, as well as other medical diagnostic procedures, physical and occupational therapy, hearing and vision services, and transportation services including ambulance. Similarly, other substances, equipment, supplies, or other items used in health care services includes medical supplies, orthotic and prosthetic devices, and durable medical equipment. In the final rule, we clarify the description of physician and other health care services and we recognize that two code sets (CPT–4 and HCPCS) are used to specify these services. In the proposed rule, we used the term ‘‘health-related services’’ to help describe these services. We believe that use of the term ‘‘health-related services’’ might suggest that these services are not health care. In an effort to prevent this confusion, and because the codes in this category are used to enumerate services meeting the definition of health care, we are using what we believe is the more appropriate term (‘‘health care services’’) to describe these services. We note that the substance of the category remains the same. The final rule has been revised to indicate that the combination of HCPCS and CPT–4 will be used for physician services and other health care services. The use of ICD–9– CM procedure codes is restricted to the reporting of inpatient procedures by hospitals. In � 162.1002 we clarify the use of medical code sets. The standard code sets are the following: ICD–9–CM, Volumes 1 and 2 (including The Official ICD–9–CM Guidelines for Coding and Reporting), is the required code set for diseases, injuries, impairments, other health problems and their manifestations, and causes of injury, disease, impairment, or other health problems. ICD–9–CM Volume 3 Procedures (including The Official ICD–9–CM Guidelines for Coding and Reporting) is the required code set for the following procedures or other actions taken for diseases, injuries, and impairments on hospital inpatients reported by hospitals: prevention, diagnosis, treatment, and management. NDC is the required code set for drugs and biologics. Code on Dental Procedures and Nomenclature is the code set for dental services. The combination of HCPCS and CPT–4 is the required code set for physician services and other health care services. HCPCS is the required code set for other substances, equipment, supplies, and other items used in health care service Hope this helps,   Greg -----Original Message----- From: Jim Moores [mailto:[EMAIL PROTECTED]] Sent: Tuesday, August 28, 2001 3:30 PM To: [EMAIL PROTECTED]; [EMAIL PROTECTED]; [EMAIL PROTECTED] Cc: George Kaye Subject: ICD9 Procedure Codes vs HCPCS Procedure Codes Hi All,     I think that this is an easy question (I hope).  When we price Outpatient Surgeries we use the APG system that uses both the ICD9 Procedure Codes and the HCPCS Procedure Codes (so I've been told).  Both data elements are in the 837 I transaction.      The question:  The 837I IG is unclear if we can require BOTH procedure codes for outpatient claims... The HCPCS seems to be situational, but without comment.  I've read that no comments means "send it if you've got it".  The difference is, we need to price accurately.     Bottom line:  Can we require Institutional Providers of Care to send us both for Outpatient Claims in some sort of contractual arrangement (network contract).     Any comments and observations gratefully accepted.   Thanks all, ********************************************************************** To be removed from this list, send a message to: [EMAIL PROTECTED] Please note that it may take up to 72 hours to process your request.