Medical codes can be frustrating and confusing for anyone who isn’t a trained medical coder. Codes are constantly evolving. New codes are added. Old codes are deleted or replaced. And, code descriptors are revised. As the backbone of health care documentation and payment systems, this is a critical thing to get right. Healthcare is a highly regulated industry and there are multiple code sets that are under the purview of different government agencies. Add to this, the general complexity surrounding the meaning of the code and its associated descriptor and you find an overwhelming situation in which health plans (aka payers) must manage frequent and unpredictable releases with little time to make changes.
The Health Insurance Portability and Accountability Act (HIPAA) requires health plans to implement the most recent version of the medical data code set by the code implementation date. The complexity of the codes coupled with the urgency of adopting newly released codes all while determining where a given code fits into current coverage policy poses an unwelcome burden. Further complicating matters, implementation dates vary based on the different code sets.
How to make decisions about the new codes
Since the volume of codes for each release and the timing are unpredictable, shifting resources to interpret and modify codes on time can place a real strain on payer organizations. A recent batch of code updates that went into effect January 1, 2023 included 139 new Category I, Category III, and Proprietary Laboratory Analysis Current Procedural Terminology (CPT) codes and late releases have been known to make providers and payers scramble.
When code sets are released throughout the year, health plans must mobilize resources and make decisions regarding new and revised codes as soon as possible. Activities center around:
- Does the code need to be added to current coverage policy?
- Is new coverage policy addressing the code appropriate?
- Is explicit non-coverage appropriate?
What questions do health plans need to answer quickly for code updates?
- Whether the procedure/service/item requires regulatory clearance or approval, and if so, has regulatory clearance been granted?
- What is the clinical indication for the procedure/service/item?
- Are there current clinical guidelines addressing the procedure/service/item?
- Is there published clinical evidence supporting the procedure/service/item?
- Are other payers addressing the technology in coverage policy?
Tools that help
In response to this burden, Medical Code Briefs help health plans address the need for quick, concise information on new code releases. Hayes, a symplr company, has developed Medical Code Briefs that contain comprehensive preliminary research about key medical codes released each quarter. As soon as new Category I Current Procedural Technology (CPT) codes, Category III CPT codes ("T" codes), Proprietary Laboratory Analyses (PLA) codes ("U" codes), and Healthcare Common Procedure Coding System (HCPCS) codes are released throughout the year, our Research Team performs preliminary research and identifies available clinical abstracts, regulations and guidelines, related Hayes reports, U.S. Food and Drug Administration (FDA) status, and major private health plan coverage.
The basics of understanding codes
Medical coding is the translation of healthcare diagnoses, services, procedures, and supplies into a language that can be used for claims, payment, tracking, and research. Different code sets are used to relay specific information from the provider to the payer:
ICD-10-CM: the International Classification of Diseases (Clinical Modification) is a coding system that allows for reporting of diagnoses. This represents the reason that a patient presents for health care services. ICD-10 also includes a procedure coding system (PCS) that is used to report hospital inpatient procedures. ICD-10 codes are maintained by the Centers for Disease Control's National Center for Health Statistics under authorization by the World Health Organization.
CPT: Current Procedural Terminology (CPT) codes describe medical procedures (e.g., tests, surgeries, evaluations, and interventions) performed by a healthcare professional. CPT is further divided into multiple code sets, including Category I, Category III, and Proprietary Laboratory Analyses (PLA) codes. This code set is published, maintained, and copyrighted by the American Medical Association (AMA).
HCPCS: Healthcare Common Procedural Coding System (HCPCS) codes primarily represent items and supplies and non-physician services not covered by CPT codes. The HCPCS code set contains numerous subsets of codes, with different applications and different mechanisms for addition, deletion and revision of codes. The Centers for Medicaid and Medicare Services (CMS) is responsible for assigning new codes, revisions, and deletions.