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PERFORMANCE MEASURE
    CODING

  HIPAA Standard Codes


 

– PERFORMANCE MEASURE CODING –
Inpatient and Outpatient HIPAA Code Standards
(Linking Quality Measure Reporting to Remuneration)

Understanding coding is vital to understanding the concepts and limitations of CMS' ability to measure performance in both inhospital and outpatient / ambulatory care settings and to understanding the complementary nature of the hospital performance measure reporting system (HQI) and the physician-targeted PVRP. The two major categories of codes are the ICD-9 CM and HCPCS codes.

  • •  2 Major HIPAA Standard Codes
    • ◊  ICD-9-CM Coding System

      ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) coding system has two parts. ICD-9 Diagnostic Codes (Vol. 1&2) are used to code signs, symptoms, injuries, diseases, and conditions. ICD-9 Procedure codes (ICD-9 Vol. 3) are used to code hospital inpatient procedures.

      ICD-9 Diagnostic codes are HIPAA standard code for inpatient AND outpatient services provided in all hospital, physician, and other healthcare facility settings. However, for procedures/services, there are two HIPAA Standard Codes, and ICD-9 procedural codes are used only for inpatient procedures.

      ICD-9-CM procedure codes are HIPAA Standard code for hospitals in inpatient settings. However, ICD-9 CM procedure codes were not designated as the HIPAA standard code for procedures in other settings (e.g., hospital outpatient services or other types of ambulatory services) or for physician inpatient or outpatient services. Hospitals may capture the ICD-9-CM procedure codes for internally tracking or monitoring hospital outpatient services; but when conducting standard transactions, hospitals cannot use ICD-9 Procedure codes to report outpatient services.

    • ◊  HCPCS Coding System

      The Healthcare Common Procedure Coding System (HCPCS) is solely a procedure coding system that is owned and developed by the American Medical Association.1 It consists of Level 1 Current Procedural Terminology (CPT) codes and Level 2 codes, which provide standardized coding for submitting claims for a variety of services, supplies, and equipment that are not identified by CPT codes (e.g., ambulance services).

      HIPAA standard transactions and code require that all hospital out-patient services at the service line level and the claim level (if the situation applies) and all physician services must be submitted according to the HCPCS codes.


      1  HCFA (the ascendant federal agency to CMS) in 1983 granted the AMA a "statutory monopoly" by agreeing to use and promote the AMA's copyrighted CPT code EXCLUSIVELY for the purposes of reimbursing Medicare and Medicaid bills from doctors for outpatient services. As a result of the endorsement by HCFA and the federal government of the AMA's copyrighted outpatient code – to the exclusion of all competitors – private insurance companies and others were also forced to adopt the CPT as their billing standard as well. The CPT code was thereby established as a fixture in doctor offices around the country. Senator Trent Lott in 2001 was unsuccessful in his attempt to overturn this monopoly.


    The critical relationship between an ICD-9 code and a CPT code is that CMS and all other payers require that the diagnosis supports the medical necessity of the procedure.

    Since both ICD-9 and CPT are numeric codes, health care consulting firms, the government, and insurers have all designed software that compares the codes for a logical relationship. For inpatient claims, ICD-9 diagnostic codes must substantiate the ICD-9 Procedure code. For out-patient transactions, the ICD-9 diagnostic codes must substantiate the 5-digit CPT code.

    For example, a bill for CPT 45378 (colonoscopy) would not be supported by ICD-9 Diagnostic code: 745.5 (Ostium secundum type atrial septal defect). Such an errant claim would be quickly identified and rejected.

The table below confirms the role of ICD-9-CM diagnostic codes and HCPCS and ICD-9 procedure codes as HIPAA Standard Code in inpatient and outpatient settings [PDF].

TABLE I. – Standard Code Sets Adopted under HIPAA
(Adapted from GAO-02-796 [PDF])
Standard Code Sets Targeted Health services Code set maintenance
ICD-9-CM Vols. 1&2
– International Classification of Diseases, 9th Revision, Clinical Modification, Volumes 1 and 2
Diagnoses, including:
diseases, injuries, impairments, other health-related problems and their manifestations; and
causes of injury, disease, impairment, or other health-related problems
National Centers for Health Statistics (NCHS) – in coordination with the World Health Organization (WHO) – through the ICD-9-CM Coordination and Maintenance Committee
(Meetings open to public)
ICD-9-CM Vols. 3
– International Classification of Diseases, 9th Revision, Clinical Modification, Volumes 3
Hospital inpatient procedures, including actions taken to prevent, diagnose, treat, or manage diseases, injuries, and impairments Centers for Medicare and Medicaid Services through the ICD-9-CM Coordination and Maintenance Committee
(Meetings open to public)
CPT
– Current Procedural Terminology (Level I of the Health Care Procedural Coding System or HCPCS)
Physician services
Hospital outpatient medical procedures and other medical services, including radiology and laboratory; physical and occupational therapy; and hearing and vision services
Home health services (effective January 1, 2004 with HCPCS Level III “local codes” elimination)
Copyrighted and maintained by the American Medical Association through the CPT Editorial Panel
(Meetings NOT open to public)
  • •  PVRP Codes (G-Codes & CPT Category II Codes)

    In order for CMS to record physician performance data on both process and outcomes measures in the Physician Voluntary Reporting Program (PVRP), CMS created G-codes and compelled the AMA to develop CPT Category II codes as a PVRP-specific link between these performance measures and the CMS-1500 claim form submitted by physicians. G-codes and CPT Category II codes, referenced together as the PVRP codes, became effective April 1, 2006. The G-code reporting is an interim reporting method until electronic submission of clinical data via CPT Category II codes through EHRs replaces this process. Category II codes are a relatively new coding mechanism developed by the AMA CPT Editorial Panel to allow for electronic reporting of quality measures by physicians.

    CMS has developed 105 G codes through April 2006 that are used to report PVRP quality data. Meanwhile, the AMA has provided CPT Category II codes for only 7 of the 16 "starter set" PVRP measures [PDF]. The AMA has developed 12 CPT® Category II codes – released on its website through March 2006 – that are to be used to report quality data. Each of the sets has assigned numerators (G codes or CPT® Category II codes indicating the types of service provided) and a denominator (reason for the services, including ICD-9-CM codes) and instructions regarding how the measure is to be reported. The reporting rate is calculated as a percentage for each of the 16 measures.

    Either a G-code or a CPT Category II code (but not both) is transmitted with CPT codes. CMS has designed the system so that every item of information needed for any measure is captured on the single claim form submitted. For each measure, CMS gives providers several options among G codes. For many measures, there are three to four possibilities: One code would be used to indicate that the patient was eligible for and is receiving a certain therapy. Another G code would be used to indicate that the patient is eligible but not undergoing a certain therapy. The remaining G code would be used to indicate that the patient was not an eligible candidate for the therapeutic choices.

    If a PVRP measure permits exclusion of a candidate, CPT Category II codes identify the candidate with exclusion modifiers. The general concept of performance measure exclusions 1P, 2P, or 3P that may be used with some measures are explained below:

    CPT Category II Performance Measure Exclusion Modifiers
    1P
    Medical Reasons
    (a)not indicated (absence of organ/limb, already received/performed, other)
    (b)contraindicated (patient allergic history, potential adverse drug interaction, other)
    2P
    Patient Reasons
    (a)patient declined
    (b)economic, social, or religious reasons
    (c)other patient reason
    3P
    System Reasons
    (a)resources to perform the services are not available
    (b)insurance coverage/payor-related limitations
    (c)other reasons attributed to health care delivery system

The table below demonstrates the methods of identification of the numerator (G-codes and/or CPT Category II codes) and denominator (ICD-9 codes and Evaluation and Management (E&M) guidelines) that are provided by CMS for 3 of the 16 PVRP performance measures. The reporting rate is calculated as a percentage for each of the 16 measures. The specifications and instructions for the complete set of 16 measures is available from CMS [PDF]. However, as of April 1, 2006, all 16 of the "starter set" measures have G-codes, whereas only 7 of the 16 measures have any CPT category II codes. Therefore, CMS intends that physicians use G-code reporting as an interim reporting method until electronic submission of clinical data via CPT Category II codes through EHRs replaces this process.

ICD-9 and PVRP Codes (G-Codes and CPT Category II Codes)
for 3 of 16 PVRP Starter-set Measures
[Technical Specifications for All 16 measures – PDF]

AMI: Aspirin at arrival for acute myocardial infarction
Numerator Codes Denominator Codes
G-code Description & CPT Cat II Alternative Description
G8006 AMI: patient documented to have received aspirin at arrival

No CPT Cat II codes available in mid-2006
Patients with acute myocardial infarction who present to hospital emergency department or are hospitalized as listed:
  ICD-9 E&M
G8007 AMI: patient not documented to have received aspirin at arrival 410.01
410.11
410.21
410.31
410.41
410.51
410.61
410.71
410.81
410.91
ED: 99281-99285;
initial hospital care: 99221-99223;
observation: 99218-99220 99234-99236;
critical care services: 99291- 99292
G8008 AMI: Clinician documented that acute myocardial infarction patient was not an eligible candidate to receive aspirin at arrival measure

No CPT Cat II codes available in mid-2006
AMI: Beta blocker at time of arrival for acute myocardial infarction
Numerator Codes Denominator Codes
G-code Description & CPT Cat II Alternative Description
G8009 AMI: patient documented to have received beta-blocker at arrival
OR
CPT Cat II code 4006F: Beta-blocker therapy prescribed
Patients with acute myocardial infarction who present to hospital emergency department or are hospitalized as listed:
  ICD-9 E&M
G8010 AMI: patient not documented to have received beta-blocker at arrival 410.01
410.11
410.21
410.31
410.41
410.51
410.61
410.71
410.81
410.91
ED: 99281-99285;
initial hospital care: 99221-99223;
observation: 99218-99220 99234-99236;
critical care services: 99291- 99292
G8011 AMI:Clinician documented that acute myocardial infarction patient was not an eligible candidate for beta-blocker at arrival measure
OR
CPT Cat II code 4006F WITH CPT modifier 1P, 2P, or 3P: Beta-blocker therapy prescribed with exclusion
Diabetes: Hemoglobin A1c control in Type I or II diabetic patient
Numerator Codes Denominator Codes
G-code Description & CPT Cat II Alternative Description
G8015 Diabetes: Diabetic patient with most recent hemoglobin A1c level (within the last 12 months) documented as greater than 9%
OR
CPT Cat II code 3046F: Most recent hemoglobin A1c level > 9.0%
Patients with diabetes:
  ICD-9 E&M
G8016 Diabetes: Diabetic patient with most recent hemoglobin A1c level (within the last 12 months) documented as less than or equal to 9%
OR
CPT Cat II code 3047F: Most recent hemoglobin A1c level <9.0%
250.00-250.93 (DM), 357.2 (polyneuropathy in DM), 362.01-362.07 (DM retinopathy), 366.41 (DM cataract), 648.00, 648.01, 648.02, 648.04 (DM in pregnancy, not gestational) visit:
99201-99205, 99211-99215 (E&M);
99341-99350 (home visit);
99304-99310 (nursing facility);
99324- 99328, 99334-99337 (domiciliary);
G0344
G8017 Diabetes: Clinician documented that diabetic patient was not an eligible candidate for hemoglobin A1c measure
OR
CPT Cat II code 3046F WITH CPT modifier 1P, 2P, or 3P: Most recent hemoglobin A1c level > 9.0% with exclusion
G8018 Diabetes: Clinician has not provided care for the diabetic patient for the required time for hemoglobin A1c measure (12 months)
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