Change Request Detail
Type of Request
HIPAA Policy
DSMO Process Completed
Business Reason
The Final Rule for Standards for Electronic Transactions released on August 17, 2000 discusses the standard data content for adopted standards which will facilitate consistent and identical implementation.  Although this includes data dictionaries, implementation specifications, and modifiers for code sets, it explicitly excludes guidelines and instructions for code sets.  The Final Rule argues that while guidelines are highly desirable, “objective, operational definitions for most codes are not available…the level of detail varies widely from code to code…the processes for developing guidelines and instructions are typically not open and include limited participation compared to the code development processes”.  The Final Rule goes on to adopt the Official ICD-9-CM Guidelines for Coding and Reporting as maintained and distributed by the Department of Health and Human Services, but does not name guidelines for other code sets. 

The American Medical Association (AMA) believes that standard implementation guidelines for code sets are essential for uniform national application of the code sets.  Since the implementation of the standard electronic transactions, health plans and providers have been permitted to implement and interpret medical data code sets as they see fit, which has undermined the intent of Administrative Simplification.  The specification of one collection of code set guidelines (ICD-9) implies that there is a process or criteria for code set guidelines similar to the code sets themselves.  At the very least, it suggests that others could be named.  The AMA believes that CPT guidelines and instructions should also be specified as a national standard for implementing CPT codes.

The instructions and guidelines contained in the CPT Book are subject to the same rigorous editorial process used to develop CPT codes.  The CPT Editorial Panel and CPT Advisors consider CPT section guidelines, specific code level instructions and definitions, and the application of modifiers in conjunction with their development of language for CPT code descriptors.  Thus, proper use of CPT codes is based on all the associated material contained in the CPT Book.  For example; simple, intermediate, and complex repair are defined in the book prior to the actual repair codes so that users understand the circumstances for reporting each.  Also, coding conventions, such as add-on codes, are explained in the guidelines.  The use of codes and descriptors apart from this information limits the functionality of CPT and its uniform application.
Recommend to NCVHS that CPT guidelines be specifically named as part of the national standard for implementing CPT codes, which would require their use in HIPAA standard transactions.  This change can be put forward in the upcoming ICD-10 Notice of Proposed Rulemaking.
DSMO Category
The DSMO believes an assessment should be conducted to determine the impact that selecting such guidelines will have on certain transactions (such as outpatient institutional claims) and the relationship with other HIPAA adopted code sets.  The DSMO recommends that an industry group including all affected stakeholders be established to explore the issues and implications prior to the adoption of any recommendations by NCVHS. The DSMO will outreach to WEDI to begin this work.
Appeal Recommendation