FHIR Chat · CPT Modifiers

Stream: C-CDA

Topic: CPT Modifiers

Paul Denning (Jan 05 2021 at 22:28):

With COVID-19 there is attention on ways to record telehealth/virtual visits.

CMS guidance on telehealth with QRDA [1] has the following example:

<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49" extension="2015-08-01"/>
<!-- Encounter Performed (V4) -->
<templateId root="2.16.840.1.113883.10.20.24.3.23" extension="2017-08-01"/>
<id root="b26e67f8-17b1-479a-a7ed-02f7962b9617"/>
<code code="99396"
    displayName="Periodic comprehensive preventive medicine reevaluation ..."
    codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT">
    <qualifier>
        <name code="VR" displayName="Virtual" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
        <value code="95"
        displayName="Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
        codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT"/>
    </qualifier>
</code>
<text>Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up</text>
<statusCode code="completed"/>
<effectiveTime>
    <low value="20200501090000"/>
    <high value="20200501094500"/>
</effectiveTime>
</encounter> ...

see [5] for xsd.

The xpath "encounter/code/qualifier/name" would probably map to FHIR Encounter.class [2]
Encounter.class uses the ActEncounterCode value set [3]

But the actual modifier code, "95" in this example, does not seem to have a place in FHIR Encounter.

Is an extension needed for CPT modifiers?

Furthermore, some CPT modifiers may not fall under the same Encounter.class ("VR").

Note that the VSAC code system browser for CPT with a filter for TTY=MP will show modifiers.

Also, where would a CMS Place of Service code [4] be within FHIR Encounter?

[1] https://ecqi.healthit.gov/sites/default/files/2020-eCQM-Telehealth-Guidance-Document-With-QRDA-Update-508.pdf
[2] http://hl7.org/fhir/encounter-definitions.html#Encounter.class
[3] http://hl7.org/fhir/v3/ActEncounterCode/vs.html
[4] https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set
[5] https://github.com/HL7/cda-core-2.0/blob/master/schema/normative/processable/coreschemas/datatypes-base.xsd#L336

Robert McClure (Jan 14 2021 at 00:34):

@Floyd Eisenberg @Lisa Nelson

Floyd Eisenberg (Jan 14 2021 at 00:43):

@Paul Denning the intent was not to reference CPT modifiers. Rather it is to reference evidence of a virtual visit which includes telemedicine. CPT modifiers are intended for billing. The measurement plan is to use clinical (not billing) data. Besides, CMS allows a set of codes intended for in-person visits to additionally cover virtual visits (I.e., sans modifier). That means the concept is clinical process (virtual) and not a CPT modifier code.

Floyd Eisenberg (Jan 14 2021 at 00:45):

@Paul Denning also, in FHIR you are correct, the Encounter.class value = VR means virtual visit.

Floyd Eisenberg (Jan 14 2021 at 00:47):

@Yan Heras please review QRDA - why is it referencing a modifier code

Last updated: Apr 12 2022 at 19:14 UTC

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FHIR Chat · CPT Modifiers · C-CDA