Uncovering the Diagnosis and Procedure Code Creation Process
There’s no escaping discussions about the Novel Coronavirus (COVID-19, as it’s also called). Every aspect of life has been touched by the spread of it. The respiratory illness COVID-19 was first identified in 2019 in Wuhan, Hubei Province, China. Since then, it’s spread internationally.
What isn’t widely discussed by the general population is a seemingly small detail that has a significant impact upon the medical community—the necessity of virus response to include the creation of new diagnosis and procedure codes. There are several codes that must be created not only to address a new disease through diagnosis but also through testing.
Some of the codes are as follows:
- ICD-10-CM, which stands for International Classification of Diseases, Tenth Revision, Clinical Modification, is the standard for reporting diseases and health conditions
- ICD-procedure codes document procedures, such as testing for a condition or the administration of a vaccine or treatment
- ICD-diagnostic codes are used to document inpatient and outpatient diagnoses
- CPT codes are used to document outpatient procedures, such as those shared above
Note that new procedure codes are needed to document the testing for a disease. Then, at a later date, if a vaccine or procedure is created to treat the disease, another new procedure code is created for that.
While there is a standard process in place for when and how codes are released, COVID-19 is a unique situation, triggering the creation of a new code outside the normal process. In this post, we provide a high-level overview of why we need these codes. We also discuss how they are created under normal circumstances as well as during an unexpected outbreak, such as the one we’re experiencing today.
Why We Need Diagnosis and Procedure Codes
As stated by the World Health Organization (WHO), diagnosis and procedure codes allow for:
- easy storage, retrieval and analysis of health information for evidence-based decision-making
- sharing and comparing health information between hospitals, regions, settings, and countries
- data comparisons in the same location across different time periods.
Every time a patient goes to the doctor, the encounter is memorialized using the set of diagnosis and procedure codes identified above, which correspond to what happened during that visit. By using specific codes for encounters, physicians have a normalized way of reporting what happens in their practices. There are thousands upon thousands of codes, each intended to document the specific diagnoses and procedures that occur in healthcare settings around the world. Codes are also important for billing and reimbursement, as physician encounters are billed based on what codes are present on the claim corresponding to the encounter. This is how insurers understand what they are paying for when their covered patients go to the doctor.
How Diagnosis and Procedure Codes are Typically Released
New ICD and DRG codes are created every year by CMS. They are typically released in the fall, with an announcement at the beginning of Q3. This allows for healthcare providers to prepare and plan for any changes to come. Codes then typically go into effect October 1, the beginning of Q4 of that year.
CPT codes are maintained by the American Medical Association and are released biannually due to new technologies and innovations being implemented to treat diseases. Applications for new or revised CPT codes can be submitted by certain parties to be reviewed by the 17-member CPT Editorial Panel. The Panel meets three times a year and addresses nearly 350 topics per year, involving 3,000+ votes on individual items. New/revised code approvals are then referred to the RVS (Relative Value Scale) Update Committee (RUC), which will conduct a survey of Qualified Health Plans (QHP) from certain medical specialties that provide the service or procedure.
Category I CPT codes are updated annually and are effective January 1st of each year. Category II CPT codes are released three times yearly (March, July, November) and become effective three months after release. Category III codes are released either January 1st or July 1st and become effective six month after date of release.
While it's helpful to understand how codes are released, it's also important to keep in mind that codes are also regularly revised and retired. Organizations need to revisit codes and their product line definitions often for this reason, especially when looking at trends over time.
How COVID-19 is Unique
While new codes are released on a regular basis, in the face of an emergency, a special meeting is held to specifically address the immediate need for an interim code. In emergency cases, CMS and AMA reserve the right to create new codes outside of the regularly scheduled updates. This process was first seen in action with the creation of emergency code U070 to document e-cigarette, or vaping, product use and associated lung injury. Interim diagnosis coding protocols are used, consisting of suggested primary and secondary diagnoses until an official code is effective with the regular release schedule. The interim protocols give different scenarios of disease progression and characteristics to specify which primary and secondary diagnoses to code.
In the case of COVID-19, the January 30, 2020 declaration by the WHO of a public health emergency of international concern led to the scheduling of an emergency meeting of the World Health Organization Family of International Classifications (WHOFIC) Network Classification and Statistics Advisory Committee (CSAC). They convened in January to discuss the creation of a specific code for the new coronavirus.
What we know about the ICD-10-CM diagnosis code for COVID-19 at this time, as shared by the American Academy of Family Physicians (AAFP), is stated below.
There was no specific code for COVID-19 in the U.S. until March 18th, when the CDC announced via a webcast meeting that the new code would be implemented on April 1st, instead of the usual October 1st date, citing ‘timely data collection needs’. The World Health Organization (WHO) has already added code U07.1 (2019-nCoV acute respiratory disease) to the international ICD-10, and the U.S. version (ICD-10-CM) will be implemented on April 1st. When ICD-11 is released in October, COVID is expected to become RA01.0 and U07.1 will return to be reserved for emergency diseases. The CDC published the following interim guidance prior to March 18th that provides insight to the April 1st update:
- For a diagnosis of COVID-19, report the code for the patient condition that is related to the COVID-19 (e.g., J12.89, "Other viral pneumonia") and B97.29, "Other coronavirus as the cause of diseases classified elsewhere."
- For suspected COVID-19, not confirmed or ruled out at the encounter, report codes for the presenting signs and symptoms. Do not report a code for coronavirus when this diagnosis is not stated in the medical record.
- For known exposure to COVID-19 (without diagnosis of COVID-19), report Z20.828, "Contact with and (suspected) exposure to other viral communicable diseases."
- For suspected exposure to COVID-19 that is ruled out after evaluation, report Z03.818, "Encounter for observation for suspected exposure to other biological agents ruled out."
The American Health Information Management Association shared that full addenda information regarding the new code and the final code title was presented at the ICD-10 Coordination and Maintenance Committee meeting that was held on March 17–18.
When attempting to understand the full impact of an illness, accurately and consistently diagnosing it becomes paramount. In order to aggregate information quickly, that consistency becomes even more important. The main way that can take place is with the formation of diagnosis and procedure coding, which provide a way to tag encounters in the data that meet the specifics for the illness at hand. In these times of uncertainty, when many things are unknown, our international system of diagnosis and procedure coding provides one area of formality that we can look to for tracking how a new disease is impacting patients.
Know too, that the team at Stratasan is still hard at work on your behalf. We’re ready to support your efforts to address specific issues that may arise at this time. Here are a few ways we can help:
- Redefining patient and physician needs after a pandemic
- Addressing the challenges of an ever-changing healthcare landscape
- Implementing the best working from home habits to control your safety AND sanity (read more about that, here)
Please reach out and schedule a time to talk, if there’s anything we can do to help.