Questions Covering the Clinical Groupings/Code Grouper Data

What are the different medical coding standards used in the PurpleLab platform?

PurpleLab includes all codes from relevant “Medical Coding Standards” used in administrative claims operations. Included “Medical Coding Standards” are as follows:

ICD: The widely recognized international system for recording diagnoses and procedures known as the International Classification of Disease (ICD) system. ICD is developed, monitored, and copyrighted by the World Health Organization (WHO) and the underlying codes and descriptions of the various versions can be applied to any diagnosis, symptom, or cause of death, ICD consists of alphanumeric codes that follow an international standard, making sure that the diagnosis will be interpreted in the same way by every medical professional both in the U.S. and internationally.

ICD9: The former version of ICD used in the U.S. was known as ICD9 (for 9th edition). The National Center for Health Statistics, Centers for Disease Control and Prevention (CDC), modified ICD-9 diagnosis codes for use in the U.S. and maintained the ICD-9-CM diagnosis code set (Volumes 1 and 2). The Centers for Medicare & Medicaid Services (CMS) developed and maintained the procedure code set (Volume 3).

ICD10: The ICD10 (10th edition) code set replaced the ICD9 on claims on and after October 1, 2015. All providers, including physicians, are required to use it in U.S. health care settings for all claims recorded by any provider or submitted to any payer on and after October 1, 2015. He ICD10 code system was developed and is maintained by the CDC. The ICD10 is a more comprehensive and complex set of codes designed to address some of the issues of ICD9. For example, ICD10 codes are longer than ICD9 codes, reducing the risk of running out of possible available codes in the future. They are also more detailed, registering finding like laterality (which side of the patient a symptom appears on), an option that has been previously absent in ICD9.

CPT/HCPCS: Current Procedural Terminology (CPT) was developed and is maintained by the American Medical Association (AMA). CMS builds on top of that codes system with the Healthcare Common Procedure Coding System (HCPCS) (which is often pronounced by its acronym as “hick picks”).  CMS defines all CPT and HCPCS codes as follows:

Level I HCPCS: Level I HCPCS codes and modifiers are the current version of CPT codes (currently CPT 4 for 4th version). The Current Procedural Terminology (CPT) (version 4) coding is a U.S. only standard for coding medical procedures, maintained and copyrighted by the American Medical Association (AMA). Where ICD9 and ICD10 codes focus on the diagnoses and procedures, CPT exclusively identifies the services provided.  CPT4 (version 4) terminology is used by providers and payers to determine how much HCPs will be paid for their services. CPT is managed by a CPT Editorial Panel, which meets three times per year to discuss current issues related to new and emerging technologies, as well as difficulties encountered with procedures and services as they relate to CPT codes.  New CPT codes as well as changes to existing CPT codes change existing CPT can be applied by submitting proposals to the CPT Editorial panel.

Level II HCPCS: Level II codes and modifiers primarily identify products, supplies, and services not included in the CPT codes (such as ambulance services; drugs; devices; and durable medical equipment, prosthetics, orthotics, and supplies). Level II HCPCS codes maintained and copyrighted by CMS maintains the code set, with the exception of the code set for dental services, or so called “D-codes”. D-codes are developed, copyrighted, and maintained by the American Dental Association (ADA).

NOTE: In order to query claims longitudinally, crosswalks between the various versions and coding systems must be developed, validated and maintained over time. PurpleLab has undertaken this effort.  We have also built a database of “allcodes” that contains all of the coding systems and standards.  We update “allcodes” to include all codes from every system.

What “Medical Coding Standards” are used the creation of Part A, Part B and Part C administrative claims?

Part A claims: involve so-called “medically necessary services” and are filed by providers using the “UB-04 medical claim form” (aka the “CMS-1450 form”). The UB-04 is the uniform institutional provider hardcopy claim form accepted by CMS for claims from its enrolled providers billing for Part A “medically necessary services”.

Part B claims: involve so-called “preventive care services” and are filed by providers using the “CMS-1500 form”. Enrolled providers use this form for billing Part B “preventive services” to Carriers which regionally administer the Part B program on behalf of CMS.  The CMS-1500 form is updated and maintained by the National Uniform Claim Committee (NUCC).

Claims related to Parts C and D of Medicare are relayed through a private insurer and should never be filed through Medicare. You won’t file Medicare claims with Parts C and D because private health plan carriers have agreements with Medicare to receive a certain amount per member every month. Part D of Medicare coverage may change depending on the person receiving care because coverage depends on the drugs involved. Some drugs aren’t covered by Part D at all. Thus claims filed through Parts C and D of Medicare should be treated like any other claim handled through a private health plan carrier.

Part C claims: involve so-called “Medicare Advantage” and are never billed to CMS.  Private insurers typically request providers to use the CMS-1500 form.  However, claims submitted under the Part C program are not in the PurpleLab platform at this time.

Different “Medical Coding Standards” are used in administering claims under Part A and UB-04 claim form relative to administering claims under Part B and the CMS-1500 claim form:

 Part A Part B
 Inpatient (IP)Other (Non-IP) Part A (IP)Carrier (Part B)
FFSDxPxDxPxDxPx
2010-2015ICD9 DIAGICD9 PROCICD9 DIAGCPT/HCPCSICD9DIAGCPT/HCPCS
2015-2016ICD10DIAGICD10 PROCICD10DIAGCPT/HCPCSICD10DIAGCPT/HCPCS
Unbundled PPSDRGDRG    
Bundled PPSBPCIBPCIBPCIBPCIBPCIBPCI

NOTE: When querying claims in the PurpleLab system, it is critical to understand which “Medical Coding Standards” are used within the portion of the claims warehouse the user is attempting to access and query in within a project. Users should take care in selecting code types to select off-the-shelf Clinical Groupers/Code Groups as well as to create custom Clinical Groupers/Code Groups. Users should refer to the table above to understand that to query procedural volumes across Part A settings (e.g., IP, OP and HHA) or across Part A and Part B, that a Clinical Grouper/Code Group must contain both ICD9/UCD10 procedure codes as well as relevant CPT/HCPCS codes.

What are the different “Clinical Groupers” or “Code Groups” built into the PurpleLab platform?

PurpleLab includes “Clinical Groupers” or “Code Groups”. In general, “Clinical Groupers” or “Code Groups are tools for clustering patient diagnoses and procedures into manageable and clinically meaningful categories. Examples of “Clinical Groupers” or “Code Groups” are the Agency for Healthcare Research and Quality (AHRQ) Clinical Classifications Software (CCS) categories, offers researchers the ability to group conditions and procedures without having to sort through thousands of codes. This “clinical grouper” makes it easier to quickly understand patterns of diagnoses and procedures so that health plans, policy makers, and researchers can analyze costs, utilization, and outcomes associated with particular illnesses and procedures.

  • To use or build “Clinical Groupers” or “Code Groups” PurpleLab built the following:
  • Conditions and Procedures Include: any and all of the individual ICD9/ICD10 diagnosis or procedure code as well as all of the individual CPT/HCPCS codes. Individual codes organized into “clinical groupers” or “code groups” make it easier to analyze patterns of diagnoses and procedures in order to understand various provider performances associated with particular illnesses and procedures.  In addition to providing access to all of the now hundreds of thousands of individual claim codes, we provide two tools:

2,000 plus pre-built and validated code groups. The Agile Provider Profiling Platform™ comes equipped with pre-built “clinical groupers” make it easier to analyze patterns of diagnoses and procedures in order to understand the various provider Experiences, Outcomes, Appropriateness and Costs associated with particular illnesses and procedures. Pre-built code groups includes:

All 48 Bundled Payments for Care Improvement (BPCI) Clinical Groupers / Code Groups

All 303 DRG Cluster Clinical Groupers / Code Groups

All 765 Medical Severity Diagnostic Related Group (MS-DRGs)

All 290 AHRQ Clinical Classifications (CCS) single-level Clinical Groupers / Code Groups for diagnoses

All 729 AHRQ Clinical Classifications (CCS) multi-level Clinical Groupers / Code Groups for diagnoses

All 231 AHRQ CCS code groups (CCS) single-level Clinical Groupers / Code Groups for procedures

All 405 AHRQ CCS code groups (CCS) multi -level Clinical Groupers / Code Groups for procedures

511 NLM Value Set Authority Center (VSAC) Clinical Groupers / Code Groups for diagnoses and/or procedures

All 17 Charlson Comorbidity Index Code Groups (related to diagnoses)

All 30 Elixhauser Comorbidity Index Code Groups (related to diagnoses)

All 79 CMS Hierarchical Condition Categories (HCC)

All 63 CMS Prescription Drug Hierarchical Condition Categories (RxHCC)

All 39 NHSN Principle Operative Procedure Categories

AND

Unlimited numbers of custom Clinical Groupers / Code Groups

Our Code Grouper tool is built into the Agile Provider Profiling Platform™. The Code Grouper tool contains 3,000 plus pre-built code groups as well as full editing capabilities. The code grouper tool includes custom code group building capabilities. Users can start de novo and build a custom code group from scratch. Alternatively, users can take one of the 2,000 plus pre-built code groups or another custom code group they previously built and copy it for further editing where they can easily add or delete codes from a library of “all codes”.

NOTE: PurpleLab’s Code Grouper tools give users the ability to use 1,500 plus pre-built “Clinical Groupers” or “Code Groups” or build a custom business specific “Clinical Grouper” or “Code Group” in just a few minutes. Once a custom “Clinical Grouper” or “Code Group” built, users can keep it private for their exclusive use only or share and publish it using criteria they control.

Relating “Clinical Groupers” or “Code Groups” to the various Settings?

As a project is being set up, the “Clinical Groupers” or “Code Groups” are scanned to see what types of codes they contain. Based on known mappings (see below) of the use of administrative codes by claim type (i.e., by Setting), the ability to select Settings (and years) may be turned off or deactivated based on the nature and type of codes within the selected “Clinical Groupers” or “Code Groups” as follows:

If the “Clinical Grouper” or “Code Group” contains DRG codes, then the Part A IP setting is “unlocked” and is “selectable” for the project

If the “Clinical Grouper” or “Code Group” contains ICD9 /ICD10 Diagnosis codes, then the Part A IP, OP, SNF, HHA and Hospice settings are all “unlocked” and are individually “selectable” for the project

If the “Clinical Grouper” or “Code Group” contains ICD9 /ICD10 Procedure codes, then the Part A IP setting is “unlocked” and is “selectable” for the project

If the “Clinical Grouper” or “Code Group” contains ICPT/HCPCS codes, then the Part A IP, OP, SNF  HHA and Hospice AND Aggregated Part B settings are all “unlocked” and are individually “selectable” for the project

Summarized below in the Code Type by Claim Type/Settings table:

 Part A Part B
 Inpatient (IP)Other (Non-IP) Part A (IP)Carrier (Part B)
DRGSelectableSelectableNANANANA
ICD9/ICD10 PROCSelectableSelectableNANANANA
ICD9/ICD10 DIAGSelectableSelectableSelectableSelectableNANA
CPT/HCPCSSelectableSelectableSelectableSelectableSelectableSelectable