General Information on CPT-5 & ICD-10 Codes

The CPT-5 project is part of an effort by the American Medical Association to make improvements in the structure and processes of the Current Procedural Terminology codes; most of us are still using CPT-4 codes, of course. Changes have been made to the e ditorial process to allow greater participation and contributions from national medical specialty societies and to expedite the development of new and revised CPT codes. CPT-5 are also supposed to produce enhancements to the structure of CPT to reflect the coding demands of the modern dynamic health care system. The project was designed to address challenges presented by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

HIPAA requires the Secretary of Health and Human Services to adopt national uniform standards for the electronic transmission of financial and administrative information. In order to be meet the requirements of HIPAA, CPT-5 will strive to fulfill the following objectives:

• Maintain CPT's position as the standard for procedural coding for the health care community, and ensure that CPT is the US and international procedural coding nomenclature that facilitates reimbursement and analysis of health care information;
• Enhance the use of CPT by practicing physicians;
• Make improvements to CPT that address the needs of various non-physician health care professionals in the CPT system and updating process, including but not limited to nurses, social workers, psychologists, optometrists, physician assistants and nurse practitioners, chiropractors, and therapists (occupational, speech, physical);
• Make improvements to CPT that addresses the needs of hospitals, managed care organizations, long-term care, and ambulatory care professional and trade associations, as well as from clinical specialty societies;
• Make improvements to CPT that addresses the needs of health care researchers;
• Develop, implement, and disseminate more comprehensive information regarding the correct usage of CPT, including guidelines, policies, and procedures;
• Develop and implement mechanisms to incorporate timely updates to CPT to reflect changing practice patterns and new technologies;
• Make systematic improvements to CPT that addresses existing inconsistencies in the numeric sections of the coding book;
• Explore issues related to the current and anticipated deployment of computer-based patient record systems and their relationship to the continued use of CPT;
• Explore issues related to the reliability of CPT coding, ie, that different users arrive at the same code for the same service;
• Explore issues related to the development of a hierarchical structure for CPT; and
• Explore needs of public and private health care payors.

The CPT-5 project was supposed to be completed and mandated in 2003. However, the silence is deafening, and I've been unable to discover any further information as to when implementation of these codes is supposed to take place nationwide. However, it was indicated that the CPT-5 codes will still be 5-number codes, just like the current codes, for the most part. I say it that way because one of the HIPAA directives stated that computer systems must be able to handle six-digit specificity for alphanumeric diagnosis codes as well as alphanumeric CPT codes.

There will be 3 category of codes:

• Category I will be the familiar 5 digit procedure codes.
• Category II is new and will consist of tracking codes for performance measures.
• Category III is also new and will include new technology, allowing for experimental technologies or services.

ICD codes are international diagnosis codes; hence the description "International Classification of Diseases. Actually, CPT codes are also international, but the standards don't seem to be as customized around the world as ICD codes are. Supposedly, ICD-10-CM and ICD-10-PCS (procedural coding system) represents a significant improvement over ICD-9-CM, because they were specifically designed to replace ICD-9-CM, and resolve many of the problems inherent in ICD-9-CM. ICD-10-CM and ICD-10-PCS:

• Reflect advances in medical care and knowledge that have occurred since the implementation of ICD-9-CM in 1979.
• Are sufficiently flexible to allow future expansion to readily accommodate medical advances, ensuring that the systems will remain useful well into the future.
• Meet HIPAA criteria for code set standards and NCVHS criteria for a procedural coding system.

The American Health Information Management Association (AHIMA), in July 2003, called upon the Department of Health and Human Services (HHS) - the code set maintenance organization for the United States - and the healthcare industry to take quick and decisive action "to expedite the adoption and implementation of ICD-10-CM and ICD-10-PCS code sets, rules, and guidelines as a replacement for ICD-9-CM in order to ensure the collection of accurate and complete healthcare data that accurately reflects the healthcare of this country."

The reason they took such a position seems legitimate. With the exception of the US and Italy, all other major countries are utilizing ICD-10 and this difference has created problems making national and international comparisons. To further complicate things, the US is using ICD-10 for "cause of death" reporting. Because cause of death and disease classifications are different, it is making statistical analysis and trend comparisons difficult as well.

Besides incompatibility problems, the current system uses antiquated terminology and leaves no room for expansion. By creating a new system, some long-standing issues can be addressed. For example, cancer registries have been using the oncology section of ICD-10 for many years because of ICD-9 limitations.

ICD-10-CM incorporates major improvements in many areas. Codes have been expanded from a maximum of five-digits to a maximum seventh-digit extension resulting in far more codes than in ICD-9-CM. There are also many other changes:

    Added:

• code extensions for external causes of injury
• code extensions for injuries
• laterality
• trimester information

    Expanded:

• alcohol and substance abuse
• injury codes
• postoperative complications

    Harmonized with other classifications:

• DSM-IV (mental health disorders)
• ICDO-2 (cancer registries)
• Nursing
• Removed relationships with procedures / procedure codes
• Revised diabetes codes to be consistent with American Diabetes Association categories

As I stated earlier, both of these code sets were supposed to be implemented in 2003 as part of HIPAA regulations. What's the delay? That, unfortunately, I haven't been able to find out. However, I would recommend that everyone be as cognizant of the pending possibly implementation, if only to make sure your computer systems are set up to be flexible enough to accept what we'd presently consider as non-standard code numbers as indicated above. Six or seven characters could become the norm; we need to be ready for when it occurs.