When you look at all the different codes used for medical billing, it's no wonder we developed Care Clusters to simplify things for you and give you exactly the procedures you're looking for. While this is by no means an exhaustive list, it should give you a good idea of the different codes available in the Carevoyance platform and why you would use one versus another or combinations of multiple codes. Most of the following will focus on codes as useful views into provider behavior, contrasting them on the basis of granularity and care setting. In other words, here at Carevoyance we find it useful to think of codes as targeting tools. You can browse codes by their respective categories in our extended search panel by typing in the codes themselves or a keyword, such as "tremor."
Care Setting Matrix
All The Codes
Diagnosis Related Groups (DRGs) don't have just to do with diagnoses. They are how hospitals typically bill for Inpatient services, and you can think of them like a bundle of codes around a particular type of service. They are high level and comprehensive as opposed to granular (there are less than 1,000 of them) and so they can be really useful for capturing procedures in a general sense. For example, there are only two DRGs related to lower joint replacement, DRGs 469 and 470. To contrast this, there are more than 50 ICD10 PCS codes for knee replacements alone.
Sometimes, DRGs are going to be the codes for you. If you're looking to target Spinal Fusions, they're going to get you a generalized view of the inpatient procedures, and since spine fusions were until recently only done in the Inpatient setting (though becoming more common in outpatient) the view using these 11 DRGs is pretty comprehensive. The DRGs allow for segmenting as well on Cervical vs Non-cervical as well as patient health level (with major comorbidity, complications, or without). However, if you wanted to see the Outpatient setting or to gain a more nuanced view of Spine Fusions (such as ACDF vs. SIJ vs. TLIF/PLIF volumes) you'd need to use another code type.
In general, CPTs are used to target procedures done in the Outpatient setting. However, while DRGs are Inpatient and CPTs are Outpatient, there is not a simple 1-to-1 mapping of one to the other. CPTs also tend to be a little more specific than DRGs.
Take knee replacements, for example: We would use CPTs 27437, 27438, and 27447 to target this procedure done in the Outpatient setting. This is more specific than using DRGs 469 and 470, which would capture all lower joint replacement (Hip and Knee).
Capturing all patients who received a procedure regardless of care setting is one of the main reasons we would create a care cluster, and a few of our most popular care clusters do exactly that, such as Major Joint Replacement, which combines Inpatient and Outpatient codes for Hip and Knee replacement into a single count.
The ICD9 standard was phased out in 2015 and replaced with ICD10, so these codes aren't relevant anymore. One thing worth noting about them though is that they were much less granular than ICD10 codes. In fact, it's common for more than a dozen ICD10 codes to map to a single ICD9 code. As ICD9 codes were four numerical digits, they had a limit of 10,000 possible codes. ICD10 PCS on the contrary is composed of seven letters and digits, giving it much more room for expansion.
ICD10 Procedure Codes
ICD Procedure codes (or ICD10 PCS) is the most complex but also the most logical coding system in place. What's amazing about these 7-digit codes is that each digit actually means something. In fact, if you know the system, you would know what a code meant even without having seen it before.
Take, for example, the following code 0SRC07Z - Replacement of Right Knee Joint with Autologous Tissue Substitute, Open Approach. The first digit (0) tells us this is a medical or surgical procedure, the second (S) that it is a lower joint, the third (R) that it is a replacement, the fourth (C) that it is on the right knee, and so on. A full breakdown of the coding logic is available here.
And, ICD10 codes are what DRGs actually break down into. When we mentioned above that DRGs are bundles, we meant they're bundles of ICD10! So we can break apart DRGs into ICD10s and get very, very specific targeting for you.
However, you're also welcome to search with them in the app. Just be aware that because they are so very specific, if you're searching Medicare claims you will likely not hit the threshold for displaying the true number as CMS requires counts be suppressed if less than 11 (represented by an asterisk - * - instead of a number).
ICD10 Diagnosis Codes
Like ICD10 PCS codes, ICD10 CM (Diagnosis) codes have a logic to them, if not as particular or complex. ICD10 diagnosis codes are three to seven alphanumeric characters, the first three of which specify the category. G20, for example, is the code for primary Parkinson's Disease, which is captured by a single code, and Essential Tremor is captured by G25.0. (Note that after the first three characters, ICD10 includes a dot (.), however we do not include this in our application). All diseases of the nervous system are represented in the range of first three characters G00 to G99.
The characters after the first three, if present, given further detail on the diagnosis (was it induced by another cause? where is it located? which encounter with the physicians is this?). For example, G21.19 (G1119 in our app) specifies "Other drug induced secondary parkinsonism."
Don't forget that unlike procedure codes, diagnosis codes can appear on future claims for a patient. If a patient were to have a knee surgery, there will be one claim to specify the code for that surgery, whereas with a patient diagnosed with Parkinson's Disease, G20 may appear on all of their future claims.
Clinical Classification Software (CCS)
The Healthcare Cost and Utilization Project (HCUP), a governmental organization, manages and bundles codes for diagnosis categories and procedure categories known as CCS codes. These work similar to a certain type of Care Cluster we sometimes put together in that they can roll up many codes together to create a single count. Whether or not a separate category exists for a disease state or procedure depends on the prevalence of that disease or procedure, with less prevalent ones being rolled up into larger groups, which we will touch on below.
CCS Diagnosis Groups
CCS Diagnosis Groups can be specific or general. One of the most specific CCS code groups is the one for Parkinson's Disease (simply G20). However, other categories can contain dozens or even hundreds of different ICD10 CM codes. Some disease states may also be uncommon enough not to receive their own category. While Parkinson's gets its own category, Essential Tremor is rolled up with a number of other codes in "Other hereditary and degenerative nervous system conditions." Within Carevoyance tools, you can actually type a diagnosis code in and it will show you the corresponding group. This also works for keywords as well.
CCS Procedure Groups
These work like the CCS Diagnosis Groups above but rather than using ICD10 CM codes they are composed of ICD10 PCS and CPT, meaning they capture both Inpatient and Outpatient procedures. Common procedures like Hip Arthroplasty and Knee Arthroplasty get their own groups, whereas codes related to any other arthroplasty are combined in the "Arthroplasty other than hip or knee category."
The great thing about these groups is that they're ready, right out of the box, and there just may be one that fits your procedure category.