Representing Medical Procedures Performed

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Type Standard / Implementation Specification Standards Process Maturity Implementation Maturity Adoption Level Federally required Cost Test Tool Availability
Standard
Final
Production
Rating 5
Yes
Free
N/A
Standard
Final
Production
Rating 5
Yes
$
N/A
Standard
Final
Production
Rating 5
Yes
Free
N/A
Standard
Final
Production
Rating 4
Yes
Free
N/A
Limitations, Dependencies, and Preconditions for Consideration Applicable Value Set(s) and Starter Set(s)
  • ICD-10-PCS  is primarily a billing code used only in inpatient settings.
  • CPT and HCPCS are codes used to report procedures and services in outpatient procedures.
  • ICD-10-PCS is named in the 2015 Edition certification rules as an optional code set for procedures.
  • SNOMED CT procedure codes can be used to describe treatment in any clinical setting and is not tied to billing, but can be cross-mapped to corresponding ICD-10-PCS and CPT/HCPCS codes.
  • Feedback requested

Comment

AMA comments on the 2018 ISA

On behalf of American Medical Association (AMA) I appreciate the ability to comment on the 2018 Interoperability Standards Advisory (ISA).

Comment:

Under “Limitations, Dependencies, and Preconditions for Consideration,” the AMA recommends that “CPT” be removed from the statement – “CPT/HCPCS are billing codes used for Outpatient Procedures.”  The CPT code set is mandated and widely used for claims processing, but it also serves in various functions outside of billing, including medical care review guidelines, medical education, patient outcomes, health services, and quality research. 

New IHE Profile IHE  [PCS] Paramedicine Care Summary 

Be aware of and promote new profile. IHE  [PCS] Paramedicine Care Summary maps the flow of the patient information from the ambulance patient record, commonly known as the electronic Patient Care Record (ePCR), to the hospital Electronic Medical Record (EMR).

From Profile - Currently, interventions and assessments are written into an ambulance electronic Patient Care Record (ePCR), and are either manually updated by the Emergency Medical Services (EMS) crew, or collected from electronic devices (e.g., hemodynamic monitor). The ePCR is updated with treatments and interventions that are administered during the transport. The hospital will not typically have access to paper or electronic versions of this patient information until the report is finished and signed in the ePCR and it is requested by the hospital. In this profile, the prehospital and paramedicine interventions and patient assessments are made available to the hospital/emergency room IT system electronically when the patient arrives, or in advance of patient arrival to the hospital. This informs medical decision making during the hospital treatment to improve patient care and to save lives

Have to be very careful with…

Have to be very careful with the scope of what is intended by procedures. Historically, HL7 distinguished surgical procedures from diagnostic procedures. Currently, all of the LRI and LOR require LOINC for the order and for the result. ISA specifies LOINC for the name of radiology tests.  If a diagnostic test is defined as a procedure as below then there will be no way to verify that by comparing codes if the test ordered got results.  

In the 4th bullet point under limitations, SNOMED CT is described as for coding treatments. That distinction regarding procedures should be made more broadly, so avoid the use of one code system to order a diagnostic study and another to report it.