May 17, 1999

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Melinna Giannini, President
Code System Concept Developer

NCVHS HEARINGS ON MEDICAL TERMINOLOGY AND CODE DEVELOPMENT

1. Definitions and Requirements for PMRI

• Historical patient record including family history, location, exposures, culture, past diagnosis and procedures, risk factors, evaluations and conclusions.
• Presenting complaint, diagnosis, measurements, tests, findings, admissions and patient tracking, prescriptions, drugs and interactions, diet, treatments, treatment plans, results and projected results.
• Administrative Transactions for the purpose of billing, referrals, coordination of payment, collection of data and assessment of cost effectiveness.

A. Comparable PMRI is required to underwrite health care costs, analyze trends, support probabilities of treatment effectiveness, assess patient risk factors and measure outcomes against a large body of existing information. This meta-data can be manipulated to uncover regional, age, sex or cultural differences in defined populations.

B. Comparability should be as precise and accurate as is economically possible. If the PMRI is not accurate, the data capture is flawed. This results in mistakes in the analysis of data. Data affects proper treatment of patients, delivery costs, provider decisions and research. A comprehensive understanding of business processes at each point in the health delivery system is essential to the development of any terminology comparisons.

2. The role our terminology plays in representing PMRI:

A. Intended purpose:

1.) To describe the procedures used by providers of acupuncture, chiropractic, holistic medicine, homeopathic, naturopathic, massage therapy, midwifery, nursing and other services regulated by state laws and supported by national training standards.

2.) To support patient choice and quality care not being captured as part of the PMRI.

3.) It is used to:

a.) define providers services in usable procedure codes.

b.) keep payers and providers from filing or accepting illegal claims

c.) support claims adjudication and medical management

d.) negotiate fee structures

e.) capture cost and outcome data

B. The heathcare domain of the terminology is: health care providers, managed care organizations, health plans, clinics, research institutes and e-commerce.

C Market acceptance includes: Use of the coding system by the largest HMO in Colorado, publishing agreements, marketing and lease agreements with leaders in electronic commerce, inclusion in the UMLS and provider buy-in. The primary gap in market acceptance is being named as a standard code set.

D. Expansion: The Home Health Care Classification, OMAHA, new procedures from the Nursing Intervention Classification, ayurvedic medicine, vitamins, minerals and organic supplements will be added June 1 to the 1999 update.

3. How does your medical terminology relate to other terminologies?
The code set was designed to capture the patient encounter in procedures as do HCPCS codes. 891 CPT codes crosswalk to this terminology of 4054 procedures. 487 CPT codes in the crosswalk are repetitions of the same CPT code. 25 Level II HCPCS developed by HCFA crosswalk to other sections of the terminology. About 600 procedures for Nursing were added to this code set in 1998 through cooperative agreement with the Nursing Intervention Classification (NIC) developers. The database currently references CPT crosswalks and plan to reference all terminologies soon.

4. How does your medical terminology relate to healthcare message format standards?
The codes were built to fit into the HCFA 1500 and the UB 92 forms in the procedure code spaces. They are 5 character, all alpha and allow 11,881,376 combinations. We participate in HL-7, ANSI X-12, DISA and CPRI for ongoing message development and currently develop our information to support administrative transactions and ISO standards.

5. Are there issues related to medical terminologies that deserve governmental attention or action?
Yes, alternative health care is affordable, popular and could potentially save the government health programs money. The patient encounter can be tracked as part of the PMRI. In one to four years, a controlled beta test to compare conventional treatment patterns to alternative heath care treatment patterns for Medicare patients should be developed. Within five to ten years, this model will show which services should be added as normal treatment options in fully insured benefits.

6. Are there issues related to the comparability of PMRI?
The main issue facing code comparability is for the stakeholders to clearly understand the difference between clinical coding in hospital settings and administrative codes for outpatient settings. Administrative billing from a provider to an insurance payer is diagnosis and procedure based because the treatments tie to direct reimbursement. This tie does not exist in hospital based DRG systems and, therefor, the business needs are quite different.

A. Role of the Government. The government is identifying standard code sets so that all stakeholders can effectively communicate the PMRI.

B. Need for coordination among terminology developers? Yes, although cooperation is surfacing between clinical terminologies, more cooperation is needed between administrative terminology developers.

C. Coordination between terminology and message standard developers. There is a general lack of understanding between HL-7 message developers and X-12 message developers. This needs to be addressed for meaningful coordination.

D. Short and Long Term Coodination. This code set offers both short and long term solutions to capture patient information to the medical record if coodinated with administrative billing codes. Treatments by licensed practitioners are broadly supplied to patients and therefor must be considered if complete PMRI is to emerge.