Da Vinci Payer Data Exchange
2.1.0-ballot - STU2 Ballot United States of America flag

This page is part of the Da Vinci Payer Data Exchange (v2.1.0-ballot: STU2.1 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions

: Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS - XML Representation

Page standards status: Trial-use

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<ValueSet xmlns="http://hl7.org/fhir">
  <id value="PDexPAInstitutionalProcedureCodes"/>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: ValueSet PDexPAInstitutionalProcedureCodes</b></p><a name="PDexPAInstitutionalProcedureCodes"> </a><a name="hcPDexPAInstitutionalProcedureCodes"> </a><a name="PDexPAInstitutionalProcedureCodes-en-US"> </a><p>This value set includes codes based on the following rules:</p><ul><li>Include all codes defined in <a href="http://terminology.hl7.org/5.3.0/CodeSystem-CPT.html"><code>http://www.ama-assn.org/go/cpt</code></a></li><li>Include all codes defined in <a href="http://terminology.hl7.org/5.3.0/CodeSystem-hcpcs-Level-II.html"><code>https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets</code></a></li><li>Include all codes defined in <a href="http://terminology.hl7.org/5.3.0/CodeSystem-HIPPS.html"><code>https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes</code></a></li><li>Include these codes as defined in <a href="http://terminology.hl7.org/5.5.0/CodeSystem-data-absent-reason.html"><code>http://terminology.hl7.org/CodeSystem/data-absent-reason</code></a><table class="none"><tr><td style="white-space:nowrap"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td><a href="http://terminology.hl7.org/5.5.0/CodeSystem-data-absent-reason.html#data-absent-reason-not-applicable">not-applicable</a></td><td>Not Applicable</td><td>There is no proper value for this element (e.g. last menstrual period for a male).</td></tr></table></li></ul></div>
  </text>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">
    <valueCode value="fm"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status">
    <valueCode value="trial-use">
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom">
        <valueCanonical
                        value="http://hl7.org/fhir/us/davinci-pdex/ImplementationGuide/hl7.fhir.us.davinci-pdex"/>
      </extension>
    </valueCode>
  </extension>
  <url
       value="http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexPAInstitutionalProcedureCodes"/>
  <version value="2.1.0-ballot"/>
  <name value="PDexPAInstitutionalProcedureCodes"/>
  <title value="Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS"/>
  <status value="active"/>
  <experimental value="false"/>
  <date value="2024-08-14T20:04:35+00:00"/>
  <publisher value="HL7 International / Financial Management"/>
  <contact>
    <name value="HL7 International / Financial Management"/>
    <telecom>
      <system value="url"/>
      <value value="http://www.hl7.org/Special/committees/fm"/>
    </telecom>
    <telecom>
      <system value="email"/>
      <value value="fm@lists.HL7.org"/>
    </telecom>
  </contact>
  <contact>
    <name value="Mark Scrimshire (mark.scrimshire@onyxhealth.io)"/>
    <telecom>
      <system value="email"/>
      <value value="mailto:mark.scrimshire@onyxhealth.io"/>
    </telecom>
  </contact>
  <contact>
    <name value="HL7 International - Financial Management"/>
    <telecom>
      <system value="url"/>
      <value value="http://www.hl7.org/Special/committees/fm"/>
    </telecom>
  </contact>
  <description
               value="The Value Set is a combination of three Code Systems: CPT (HCPCS I), HCPCS II procedure codes, and HIPPS rate codes. They are submitted by providers to payers to convey the specific procedure performed. Procedure Codes leverage US Core Procedure Codes composition.

The target set for this value set are the procedure codes from the CPT and HCPCS files and the rate codes from the HIPPS files.

The Current Procedural Terminology (CPT) code set, created and maintained by the American Medical Association, is the language of medicine today and the code to its future. This system of terminology is the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs. CPT coding is also used for administrative management purposes such as claims processing and developing guidelines for medical care review. Each year, via a rigorous, evidence-based and transparent process, the independent CPT Editorial Panel revises, creates or deletes hundreds of codes in order to reflect current medical practice.

Designated by the U.S. Department of Health and Human Services under the Health Insurance Portability and Accountability Act (HIPAA) as a national coding set for physician and other health care professional services and procedures, CPT’s evidence-based codes accurately encompass the full range of health care services.

All CPT codes are five-digits and can be either numeric or alphanumeric, depending on the category. CPT code descriptors are clinically focused and utilize common standards so that a diverse set of users can have common understanding across the clinical health care paradigm.

There are various types of CPT codes:

**Category I:** These codes have descriptors that correspond to a procedure or service. Codes range from 00100–99499 and are generally ordered into sub-categories based on procedure/service type and anatomy.

**Category II:** These alphanumeric tracking codes are supplemental codes used for performance measurement. Using them is optional and not required for correct coding.

**Category III:** These are temporary alphanumeric codes for new and developing technology, procedures and services. They were created for data collection, assessment and in some instances, payment of new services and procedures that currently don’t meet the criteria for a Category I code.

**Proprietary Laboratory Analyses (PLA) codes:** Recently added to the CPT code set, these codes describe proprietary clinical laboratory analyses and can be either provided by a single (solesource) laboratory or licensed or marketed to multiple providing laboratories that are cleared or approved by the Food and Drug Administration (FDA)). This category includes but is not limited to Advanced Diagnostic Laboratory Tests (ADLTs) and Clinical Diagnostic Laboratory Tests (CDLTs), as defined under the Protecting Access to Medicare Act of 2014 (PAMA).

To obtain CPT, please see the license request form [here](http://info.commerce.ama-assn.org/ama-data-file-request-2020)

The Level II HCPCS codes, which are established by CMS's Alpha-Numeric Editorial Panel, primarily represent items and supplies and non-physician services not covered by the American Medical Association's Current Procedural Terminology-4 (CPT-4) codes; Medicare, Medicaid, and private health insurers use HCPCS procedure and modifier codes for claims processing.  Level II alphanumeric procedure and modifier codes comprise the A to V range.

General information can be found here: [https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo](https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo)

Releases can be found here: [https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets](https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets)

These files contain the Level II alphanumeric HCPCS procedure and modifier codes, their long and short descriptions, and applicable Medicare administrative, coverage and pricing data.

The Health Insurance Prospective Payment System (HIPPS) rate codes represent specific sets
of patient characteristics (or case-mix groups) health insurers use to make payment
determinations under several prospective payment systems. Case-mix groups are
developed based on research into utilization patterns among various provider types. For
the payment systems that use HIPPS codes, clinical assessment data is the basic input. A
standard patient assessment instrument is interpreted by case-mix grouping software
algorithms, which assign the case mix group. For payment purposes, at least one HIPPS
code is defined to represent each case-mix group. These HIPPS codes are reported on
claims to insurers.
Institutional providers use HIPPS codes on claims in association with special revenue
codes. One revenue code is defined for each prospective payment system that requires
HIPPS codes. HIPPS codes are placed in data element SV202 on the electronic 837
institutional claims transaction, using an HP qualifier, or in Form Locator (FL) 44
(\&quot;HCPCS/rate\&quot;) on a paper UB-04 claims form. The associated revenue code is placed in
data element SV201 or in FL 42. In certain circumstances, multiple HIPPS codes may
appear on separate lines of a single claim.

HIPPS codes are alpha-numeric codes of five digits. Each code contains intelligence,
with certain positions of the code indicating the case mix group itself, and other positions
providing additional information. The additional information varies among HIPPS codes
pertaining to different payment systems, but often provides information about the clinical
assessment used to arrive at the code. Which positions of the code carry the case mix
group information may also vary by payment systems."/>
  <jurisdiction>
    <coding>
      <system value="urn:iso:std:iso:3166"/>
      <code value="US"/>
      <display value="United States of America"/>
    </coding>
  </jurisdiction>
  <copyright
             value="Current Procedural Terminology (CPT) is copyright 2020 American Medical Association. All rights reserved
See information on the use of HCPCS Level I (proprietary and owned by American Medical Association) and Level II codes [here](https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/HCPCS_Coding_Questions)
CMS maintains HIPPS. There are no known constraints on the use of HIPPS. See more information about HIPPS codes [here](https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes)"/>
  <compose>
    <include>
      <system value="http://www.ama-assn.org/go/cpt"/>
    </include>
    <include>
      <system
              value="https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"/>
    </include>
    <include>
      <system
              value="https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes"/>
    </include>
    <include>
      <system
              value="http://terminology.hl7.org/CodeSystem/data-absent-reason"/>
      <concept>
        <code value="not-applicable"/>
        <display value="Not Applicable"/>
      </concept>
    </include>
  </compose>
</ValueSet>