Coding

	HCPCS code implemented as a result of the research study ICD-9-CM code implemented as a result of the research study CPT code implemented as a result of the research study

There are several major medical coding systems used in the United States for use of classifying services, diagnoses, diseases, procedures, products, drugs, supplies and medical devices/equipment related to heath care. The two primary systems are the Health Care Procedure Coding System (HCPCS) and the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).

Health Care Procedure Coding System (HCPCS)

The Health Care Procedure Coding System (HCPCS) is used to report hospital outpatient and physician services and consists of two levels.

• Level I Current Procedure Terminology codes (CPT)
• Level II National Codes

HCPCS Level I Current Procedure Terminology codes (CPT)

Level I of HCPCS consists of Current Procedural Terminology (CPT) codes which are published by the American Medical Association (AMA) and updated/revised annually. The purpose of the CPT coding system is to provide uniform language that accurately describes medical, surgical, and diagnostic services. CPT codes are associated with a code for classification of diseases, called an ICD-9 Code, (International Classification of Diseases, 9th Revision, Clinical Modification). The relationship between an ICD-9 code and a CPT code is that the diagnosis supports the medical necessity of the procedure. See ICD-9-CM section.

There are three categories of CPT codes:

Category I

Category I codes are the five-digit numeric codes included in the main body of CPT. These codes represent procedures that are consistent with contemporary medical practice and are widely performed. Codes assigned to this category have met certain criteria including:

• Procedure or service approved by the Food and Drug Administration (FDA)
• Procedure or service commonly performed by health care professionals nationwide
• Procedure or service’s clinical efficacy is proven and documented

Category II

Category II codes are supplemental tracking codes that are intended to be used for performance measurement. In compliance with ongoing changes being made because of HIPAA regulations, these codes provide a method for reporting performance measures.

Category III

Category III codes represent temporary codes for new and emerging technologies. They have been created to allow for data collection and utilization tracking for new procedures or services. Category III codes are different from Category I CPT codes in that they identify services that may not be performed by many health care professionals across the country, do not have FDA approval, nor does the service/procedure have proven clinical efficacy. To be eligible for a Category III code, the procedure or service must be involved in ongoing or planned research. The rationale behind these codes is to help researchers track emerging technology and services to substantiate widespread usage and clinical efficacy.

The Code Process

Adding, modifying, or deleting of CPT codes is performed by a review process involving a CPT Editorial Panel and a CPT Advisory Panel. Each proposed coding change must be supported by peer-reviewed literature. CPT Codes, Category I, are reviewed annually with an update issued in the fall of each year with the new codes taking effect in January. CPT Codes, Category I vaccine product codes, Category II and Category III, are released twice a year in January and July with a six month period for implementation.

Each proposed CPT code must be supported by peer-reviewed literature. Location of documentation to support the use of a particular research study as support for a new CPT code is difficult as the reports from the review process are not publicly available. What is helpful is reviewing the literature, especially from trade publications, to locate evidence that findings from a research study were used to support the implementation of new CPT codes. In some instances, contact with policy-makers may be required in order to confirm that findings from a research study resulted in a new CPT code.

For example, review of the literature and confirmation with policy-makers revealed that the findings from the Ocular Hypertension Treatment Study (OHTS) resulted in the creation of a new CPT Code, Category III for corneal pachymetry, with follow-up to a CPT Category I code within four years.

Prior to 2002, a CPT code specific to pachymetry did not exist. Pachymetry was assigned as a Category III code (CPT 0025T, Determination of corneal thickness, with interpretation and report, bilateral), effective as of January 2002. As of January 2004, a Category I code, (CPT 76514, Ophthalmic ultrasound, echography, diagnostic; corneal pachymetry, unilateral or bilateral, determination of corneal thickness), was assigned. The move from a category III to a category I is evidence that a pachymetry, a “new and emerging technology,” demonstrated clinical efficacy.

According to the CPT Assistant: Authoritative Coding Information:

Corneal pachymetry (the measurement of corneal thickness) is an essential tool for glaucoma diagnosis and management because measurement of IOP is affected by the thickness of the cornea . . . The determination of an accurate IOP improves the diagnosis, screening and management of patients with glaucoma and OHT.

(Source: “CPT Assistant: Authoritative Coding Information.” The American Medical Association, July 2004)

HCPCS Level II National Codes

According to the Centers for Medicare and Medicaid Services, Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician’s office.

Recommendations for new or revised HCPCS are submitted to the CMS HCPCS Workgroup from public and private sectors. The final decision is made by CMS. New or revised codes are effective as of January 1 of each year and changes are noted in the annual HCPCS release.

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)

ICD-9-CM is used by health care providers for uniform classification of diagnoses and procedures. A diagnosis or procedure coded in the ICD-9-CM supports the medical necessity of a medical procedure or service in a CPT code. The National Center for Health Statistics (NCHS) is responsible for classification of diagnoses and the Centers for Medicare and Medicaid Services (CMS) are responsible for the classification of procedures.

Proposals for new or revised ICD-9-CM procedure codes are submitted to the ICD-9-CM Coordination and Maintenance Committee from public and private sectors. Proposals for a new code should include a description of the code being requested, and rationale for why the new code is needed. Supporting references and literature may also be submitted. Public meetings are held to discuss the proposals with final decisions made by the Director of NCHS and the Administrator of CMS. New or revised codes are effective as of October 1 of each year and changes are noted in official code revision packages referred to as addenda.

Assessment

Review of the literature and personal and anecdotal knowledge of research study investigators who may know of efforts by policy-makers to recommend new or revised medical codes is helpful in order to track implementation of new or revised medical codes based on findings from a research study. What is especially helpful is reviewing the literature, especially from trade publications, to locate evidence that findings from a research study were used to support the implementation of new or revised medical codes. Documentation used to support implementation of new or revised codes is difficult to locate and in some instances, may not be publicly available. Contact with policy-makers may be required in order to confirm that findings from a research study resulted in a new or revised medical code.

	Search using the keywords; title of the research study; the disease, condition or disorder; the specific medical specialty of the disease, disorder or condition; or name of the primary investigator/s.

For resources that may be helpful for review of the literature, see Knowledge Transfer: Mass Media and Knowledge Transfer: Reviews.

 

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Last updated: May 4, 2009