Greg
Just one small comment: Secretary Thompson has informally indicated
that NDCs are not necessarily going to be the required codes for drugs
and biologics for claims outside of retail pharmacy. The now-famous
HCPCS "J-codes" will also be allowed. However, there has not (to
my knowledge) been any formal ammendment to the rule to date.
j
[EMAIL PROTECTED] wrote:
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
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,
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