Stream: implementers
Topic: Combine CPT codes
Paul Swarts (Jan 13 2021 at 07:54):
I have a question on how to combine CPT codes a FHIR ServiceRequest for the CDS Hooks order-select protocol
For a Diagnostic order 'CT Hip Arthrogram' are two CPT codes needed 73701 (CT Lower Extremity With Contrast), 27093 (Injection Procedure Hip Arthrogram) in our organization this procedure is has also a combined code "CT Hip Arthrogram"
In the FHIR ServiceRequest we want to put both our internal combined-code and the CPT codes.
"resource": {
"resourceType": "ServiceRequest",
"code": {
"coding": [
{
"code": "CT Hip Arthrogram",
"display": "CT Hip Arthrogram",
"system": "organization-code-system"
},
{
"code": "73701",
"display": "CT Lower Extremity With Contrast",
"system": "http://www.ama-assn.org/go/cpt"
},
{
"code": "27093",
"display": "Injection Procedure Hip Arthrogram",
"system": "http://www.ama-assn.org/go/cpt"
}
],
"text": "CT Hip Arthrogram"
},
}
However this is semantically incorrect since all codes ("CT Hip Arthrogram", 73701", "27093") in the CodeableConcept (https://www.hl7.org/fhir/datatypes.html#Coding) shall be have the same meaning but only in a different form.
Ideally the CPT codes shall be combined
"resource": {
"resourceType": "ServiceRequest",
"code": {
"coding": [
{
"code": "CT Hip Arthrogram",
"display": "CT Hip Arthrogram",
"system": "organization-code-system"
},
{
"code": "73701+27093",
"display": "CT Lower Extremity With Contrast, Injection Procedure Hip Arthrogram",
"system": "http://www.ama-assn.org/go/cpt"
}
],
"text": "CT Hip Arthrogram"
},
}
But I can't find any spec on how to combine CPT codes in expressions. Is there any?
Split the ServiceRequest into 2 requests is also not correct since the internal code doesn't match one of the CPT codes
"resource": {
"resourceType": "ServiceRequest",
"code": {
"coding": [
{
"code": "CT Hip Arthrogram", => NOT CORRECT since CPT 73701 only covers a part of "CT Hip Arthrogram"
"display": "CT Hip Arthrogram",
"system": "organization-code-system"
},
{
"code": "73701",
"display": "CT Lower Extremity With Contrast",
"system": "http://www.ama-assn.org/go/cpt"
}
],
"text": "CT Hip Arthrogram"
},
}
"resource": {
"resourceType": "ServiceRequest",
"code": {
"coding": [
{
"code": "CT Hip Arthrogram", => NOT CORRECT since CPT 27093 only covers a part of "CT Hip Arthrogram"
"display": "CT Hip Arthrogram",
"system": "organization-code-system"
},
{
"code": "27093",
"display": "Injection Procedure Hip Arthrogram",
"system": "http://www.ama-assn.org/go/cpt"
}
],
"text": "CT Hip Arthrogram"
},
}
Is there any FHIR extension or syntax that helps me to solve the above coding issue?
Lloyd McKenzie (Jan 14 2021 at 05:09):
@Rob Hausam
Vassil Peytchev (Jan 14 2021 at 15:48):
I don't think this is a terminology question. It seems to me that this is an example where either ServiceRequest.code needs to allow more than one value, or an explanation how multiple billing codes can be mapped to a single ServiceRequest
Lloyd McKenzie (Jan 14 2021 at 19:34):
I believe there's a syntax for post-coordinating multiple CPT codes?
Grahame Grieve (Jan 14 2021 at 19:35):
yes I just dug up the topic
Rob Hausam (Jan 15 2021 at 07:11):
Yes, if CPT defines a "syntax" for this (even if rudimentary), then that should be used to combine the two codes as a post-coordinated expression and use that for the value of ServiceRequest.code.coding.code. I don't recall what the CPT manual describes in this regard, though. It sounds like @Grahame Grieve has found something?
Paul Swarts (Jan 15 2021 at 07:17):
Thanks all for the replies so far. I was looking for a post-coordinated expression syntax for CPT, but I could not find anything on this via Google. @Grahame Grieve : I am really interested that topic
Grahame Grieve (Jan 15 2021 at 19:28):
@Corey Smith we need to solve this, but I don't recall that we discussed it? Who at AMA should have an opinion?
Corey Smith (Jan 15 2021 at 20:12):
Hi all. CPT does have an ability to add modifiers to codes. However, I don't think it solves this specific problem. To clarify, you are trying to express "CT Hip Arthrogram" in CPT? If that's the case, I will get an answer from the CPT team. I will get back to you as soon as I get an answer. Will ask someone now...
Vassil Peytchev (Jan 15 2021 at 20:54):
I believe the exact question, based on this:
For a Diagnostic order 'CT Hip Arthrogram' are two CPT codes needed 73701 (CT Lower Extremity With Contrast), 27093 (Injection Procedure Hip Arthrogram)
is:
Is there a way to present the two CPT codes above as a post-coordinated expression, or is there a different CPT code that exactly expresses "CT Hip Arthrogram"?
Corey Smith (Jan 15 2021 at 21:36):
Ok..just spoke with one of the AMA's CPT coding experts...here goes:
- The specific codes 73701+27093 can be combined per the rules in CPT and as specified by the NCCI code edits.
- There is not a specified grammar in CPT, like in SNOMED, for how codes can and can't be combined based on a defined concept model.
- CPT does provide guidance on when codes can and can't be combined from a clinical perspective. For example, if there is a code for a Tonselectomy, CPT woud tell you not to combine that code with Incision prpcedure because an incision is included in the scope of the Tonselectomy code. These rules are called "parentheticals" and appear in the CPT book and can also be found in a machine processable version of CPT called CPT Link.
- Each payer organization will also specify, per there payment policies, when codes can and can't be combined. This is independent of CPT. In the case of CMS, these "code edits" are defined by the National Correct Coding Initiative Edits https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd
Corey Smith (Jan 15 2021 at 21:39):
One last thing...in the context of a US claim form, it is my understanding that when multiple CPT codes are listed, this is interpreted as an "AND". For example, a claim containing codes A+B would be interpreted as A AND B as opposed to A OR B. Don't quote me on this but I'm fairly certain this is the case.
Hope this helps...if not, let me know and I can try to come up with a better answer.
Vassil Peytchev (Jan 16 2021 at 01:17):
There is not a specified grammar in CPT, like in SNOMED, for how codes can and can't be combined based on a defined concept model.
Just to be clear, is there a defined syntax on how codes are combined? If the defined syntax is (from the example) 73701+27093, is there something in FHIR that can describe how to check for and interpret it?
Rob Hausam (Jan 16 2021 at 15:53):
We can and should define a syntax (likely a very simple one) for doing this in FHIR and include a section in the Using CPT with FHIR page (in the core spec now or possibly ultimately in THO) that describes it. The syntax obviously needs to be consistent with the guidance in the CPT manual and the way that this is being done in practice, and ideally and hopefully it should be approved by the AMA (the owner/publisher of CPT). I expect that the syntax would be something like "include the codes (only 2 max?) separated by a specified character". And I think likely that the specified separating character would be either a space (maybe that's preferable?) or a '+' or possibly something else, which again I think should be decided based on what is generally being done in practice. That's my take on how we would go about this.
Grahame Grieve (Jan 17 2021 at 20:34):
yes. @Corey Smith either AMA or HL7 needs to come up with the syntax here. Does AMA want us to make one up, or do you want to do it?
Paul Swarts (Jan 18 2021 at 06:38):
Thank you for all your answers. I am really interested in the outcome. Let me know when I can help
Robert McClure (Jan 19 2021 at 16:25):
@Corey Smith Your comment
in the context of a US claim form, it is my understanding that when multiple CPT codes are listed, this is interpreted as an "AND". For example, a claim containing codes A+B would be interpreted as A AND B as opposed to A OR B. Don't quote me on this
Actually needs to be nailed down, so we do need something quotable because FHIR specifically says all the codings in a codableConcept are equivalent for use. We've explicitly not yet dealt with combining concepts to form an expression as a FHIR construct (versus as defined in a code system, eg: SCT CG.) This is a gap IMO that we really need to fill. via some sort of extension or perhaps guidance. @Rob Hausam I agree this means some sort of simple syntax FHIR-based that can be aligned with guidance code systems provide.
Lloyd McKenzie (Jan 19 2021 at 16:57):
I don't think we've ever said that all codings in a CodeableConcept are equivalent for use - some are going to have more detail than others, and some will be recognized by certain recipients and not by others. So there will almost certainly be preferential treatment in terms of use.
Corey Smith (Jan 20 2021 at 20:40):
I will bring this request back to my CPT colleagues to get their input. My opinion/going in position is that defining a general syntax for how to combine codes from any code system that covers 80% of the code combination use cases (e.g. AND, OR, NOT?) seems like a good place to start. Providing a means for each code system to provide their own grammar/syntax for more complex operations (e.g. SNOMED CG) may then be the next priority. Just my initial thoughts... Thanks for including me in the discussion.
Grahame Grieve (Jan 20 2021 at 21:45):
the underlying semantics of combination vary between different code systems, so FHIR doesn't aim to define a single unifying grammar/syntax. I do think it would be good for CPT to define a single syntax for combinations that would be useable in any context where CPT codes are exchanged on the wire
Corey Smith (Jan 20 2021 at 21:53):
I agree that how to interpret what an AND, OR, and NOT means is specific to a code system. I need to give some more thought to whether or not the syntax/expression of logical operators should be done at a code system level. It would seem to me that having each code system define how it expresses "AND", "OR", and "NOT" could lead to variability in implementations that may not add any value. I won't say anymore at this point because I haven't given this much thought and respect the fact you all have likely thought about this issue more than i have. Appreciate the opportunity to comment on this and to learn... I will share this with my colleagues.
Grahame Grieve (Jan 20 2021 at 22:27):
well, it's a question of moving the deck chairs around. We had a common syntax in CDA, but people pretty much ended up inventing ways to shoe-horn meaning into the syntax, which was it's own source of variability, as well as being unsafe since the semantics didn't match.
We prefer consistency between code systems, but that depends on having underlying semantic consistency. It looks to me like the CPT combination codes are a lot like ICD ones, and so it's natural to follow a similar approach. If I'm right
Rob Hausam (Jan 20 2021 at 22:30):
Yes, I agree that the syntax for CPT should likely be similar to ICD. But I think that the CPT syntax likely will be even simpler than some of the permutations that we've included for ICD (particularly for the requirements from Germany).
Carol Macumber (Jan 28 2021 at 16:15):
@Rob Hausam and @Robert McClure do we have a vocab action item/ticket to start working on this? I'd suggest we get it on the co-chair call agenda as something to track/work on after all the other items we have prioritized. @Rob Hausam , I'd like to learn more about what we've already included as a syntax for ICD as it sounds like that's being suggested as the basis for a syntax that can be applied elsewhere, like CPT.
@Carmela Couderc @Reuben Daniels @Ted Klein
Rob Hausam (Jan 28 2021 at 16:39):
@Carol Macumber As far as I know a tracker hasn't been entered for this yet. I'm happy for @Paul Swarts or someone to enter one, or I can. The guidance that we currently have for ICD-[X] is here. I think the ICD guidance is for a rather similar and analogous situation and is a potential source of precedent that we can use with CPT. But I don't think it is actually a "basis" for what we do with CPT, as that should be based on the current standard practices when multiple CPT codes are required or are being used in combination.
Paul Swarts (Jan 28 2021 at 17:39):
@Rob Hausam I do not know where enter the tracker, so it would be great if you can do this. Can you share a link to the tracker? Thanks a lot for all the work
Rob Hausam (Jan 29 2021 at 14:24):
I'll plan to enter that this morning and will post the link.
Rob Hausam (Jan 30 2021 at 15:50):
It took me a little longer to get it done, but I've created J#30768 for this issue. For now I've assigned it to the Vocabulary WG, but at some point (now or later) it will need to be either tagged or re-assigned to HTA for their consideration. @Paul Swarts @Carol Macumber
Last updated: Apr 12 2022 at 19:14 UTC
