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Most CMS measures rely at least in part on the use of various code sets for classifying health care provided in the United States. Any codes that are required for the measure will need to be listed along with their source. Any instructions pertaining to their use need to be explicitly stated. Specifications may require certain codes to be accompanied by certain other codes, or to occur in certain positions, or on claims from specific provider types. Some code sets may require copyright statements to accompany their use. CPT® is a registered trademark of the American Medical Association (AMA). The Current Procedural Terminology (CPT) code sets are owned and maintained by the AMA and require current copyright statements to accompany their use. Logical Observation Identifiers Names and Codes (LOINC), copyrighted by the Regenstrief Institute and Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT), are other proprietary code sets that should be properly presented.

Below are some commonly used code sets along with some consideration for their use.

International Classification of Diseases (ICD)

International Classification of Diseases (ICD) is used for identifying data on claims records, data collection for use in performance measurement, and reimbursement for Medicare/Medicaid medical claims. ICD is an epidemiological classification used to identify diagnoses (diseases, injuries, and impairments). The U.S. version also includes procedures (surgical, diagnostic, and therapeutic).

Although the ICD-9-CM Coordination and Maintenance Committee is a federal committee, suggestions for modifications come from both the public and private sectors. Interested parties are asked to submit recommendations for modification prior to a scheduled meeting. Proposals for a new code should include a description of the code being requested, and rationale for why the new code is needed. Supporting references and literature may also be submitted. Proposals should be consistent with the structure and conventions of the classification.

These meetings are open to the public; comments are encouraged both at the meetings and in writing. Recommendations and comments are carefully reviewed and evaluated before any final decisions are made. No decisions are made at the meetings. The ICD-9-CM Coordination and Maintenance

Statistics (NCHS) and the administrator of CMS. Final decisions are made after the December meeting and become effective October 1 of the following year.8

On January 16, 2009, the U.S. Department of Health and Human Services (HHS) released a final rule mandating that everyone covered by the Health Insurance Portability and Accountability Act (HIPAA) must implement ICD-10 for medical coding by October 1, 2013. However, on April 17, 2012 HHS published a proposed rule that would delay the compliance date for ICD-10 from October 1, 2013 to October 1, 2014.9

The current system, International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9- CM), does not provide the necessary detail for patients’ medical conditions or the procedures and services performed on hospitalized patients.

The new classification system provides significant improvements through greater detailed information and the ability to expand in order to capture additional advancements in clinical medicine.

ICD-10-CM/PCS consists of two parts:

 ICD-10-CM—The diagnosis classification system developed by the Centers for Disease Control and Prevention for use in all U.S. health care treatment settings. Diagnosis coding under this system uses 3–7 alpha and numeric digits and full code titles, but the format is very much the same as ICD-9-CM.

 ICD-10-PCS—The procedure classification system developed by the Centers for Medicare & Medicaid Services (CMS) for use only in the U.S. for inpatient hospital settings. The new

procedure coding system uses 7 alpha or numeric digits while the ICD-9-CM coding system uses 3 or 4 numeric digits.10

As a result of the revised timeline for ICD-10 implementation, NQF also published a revised timeline regarding the requirements for measures using ICD codes:

 October 2011—Measure developers/stewards will be required to submit ICD-9-CM and ICD-10- CM/ PCS codes for review for all endorsement-maintenance projects.

 October 2014—Measure developers/stewards will be required to submit ICD-10-CM/ PCS for HIPAA transactions.

 January 2015—ICD-9-CM codes will no longer be accepted for measure specifications after December 31, 2014.11

When a developer submits ICD-10 codes, then the following requirements should also be met:

8_{ICD-9-CM Coordination and Maintenance Committee. Available at: http://www.cdc.gov/nchs/icd/icd9cm maintenance.htm. Accessed July 31, 2012.} 9

Centers for Medicare & Medicaid Services. ICD-10, Statute and Regulations. Available at: http://www.cms.gov/ICD10/02d CMS ICD- 10 Industry Email Updates.asp#TopOfPage. Accessed July 31, 2012.

10_{Centers for Medicare & Medicaid Services. ICD-10 CM/PCS – An Introduction. Available at: http://www.cms.gov/ICD10/Downloads/ICD-10Overview.pdf.}

Accessed July 31, 2012.

11_{The National Quality Forum. Measure Developer Webinar, June 18, 2012. Available at:}

 Provide a statement of intent for the selection of ICD-10 codes, chosen from the following:

o Goal was to convert this measure to a new code set, fully consistent with the intent of the

original measure.

o Goal was to take advantage of the more specific code set to form a new version of the

measure, but fully consistent with the original intent.

o The intent of the measure has changed.

 Provide a spreadsheet, including:

o A full listing of ICD-9 and ICD-10 codes, with code definitions. o The conversion table (if there is one).

 Provide a description of the process used to identify ICD-10 codes, including:

o Names and credentials of any experts who assisted in the process. o Name of the tool used to identify/map to ICD-10 codes.

o Summary of stakeholder comments received.12

Below is the schedule of updates to ICD-9 and ICD-10 Code Sets during the transition period.  October 1, 2011—Last annual update to ICD-9 and ICD-10. Code set partial freeze began.  October 1, 2012—Limited updates to ICD-9 and ICD-10 for new technologies (ICD-9 ends after

this update).

 October 1, 2013—Claims for services provided on or after this date must use ICD-10 codes for medical diagnosis and inpatient procedures.

 October 1, 2014—Regular updates to ICD-10 code sets begins. Code set partial freeze ends.

Current Procedural Terminology, Fourth Edition (CPT4®₎

CPT is a registered trademark of the American Medical Association (AMA) for the Current Procedural Terminology, Fourth Edition (CPT4). The CPT Category I or CPT codes is a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians. The purpose of the terminology is to provide a uniform language that will accurately describe medical, surgical, and diagnostic services, and will thereby provide an effective means for reliable nationwide communication among physicians, patients, and third parties.13 This code set is updated annually. Each CPT record corresponds to a single observation or diagnosis. The CPT codes are not intended to transmit all possible information about an observation, or diagnosis. They are only intended to identify the observation or diagnosis. The CPT code for a name is unique and permanent.

12_{The National Quality Forum. ICD-10-CM/PCS Coding Maintenance Operational Guidance: A Consensus Report. Available at:}

http://www.qualityforum.org/Publications/2010/10/ICD-10-CM/PCS Coding Maintenance Operational Guidance.aspx. Accessed July 31, 2012.

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Centers for Medicare & Medicaid Services. Data Submission Specifications Utilizing HL7 QRDA Implementation Guide Based on HL7 CDA Release 2.0

Version: 2.0 Last Modified: July 01, 2010 Available at: https://www.cms.gov/PQRI/20 AlternativeReportingMechanisms.asp#TopOfPageAccessed August 7, 2012.

Current Procedural Terminology, Fourth Edition (CPT®) is copyrighted by the AMA, All Rights Reserved. CPT is a registered trademark of the AMA.

CPT Category II or CPT II codes, developed through the CPT Editorial Panel for use in performance measurement, serve to encode the clinical actions described in a measure’s numerator. CPT II codes consist of five alphanumeric characters in a string ending with the letter “F.” CPT II codes are updated annually and are not modified or updated during the year.

When publishing measures that use CPT codes, users must include a set of notices and disclosures required by the AMA. Contact the COR/GTL to obtain the current full set of notices and disclaimers that includes:14

 Copyright notice  Trademark notice

 Government rights statement  AMA disclaimer

For questions regarding the use of CPT codes, contact the AMA CPT Information and Education Services at 800.634.6922 or via the Internet at http://www.ama-assn.org.

SNOMED CT15

Systematized Nomenclature of Medicine Clinical Terms or SNOMED CT. is a registered trademark of SNOMED International. SNOMED CT contains over 357,000 health care concepts with unique meanings and formal logic-based definitions organized into hierarchies. The fully populated table with unique descriptions for each concept contains more than 957,000 descriptions. Approximately 1.37 million semantic relationships exist to enable reliability and consistency of data retrieval.

SNOMED International maintains the SNOMED CT technical design, the core content architecture, and the SNOMED CT Core content. SNOMED CT Core content includes the technical specification of

SNOMED CT and fully integrated multi-specialty clinical content. The Core content includes the concepts table, description table, relationships table, history table, and ICD-9-CM mapping, and the Technical Reference Guide.

Each SNOMED record corresponds to a single observation. The SNOMED codes are not intended to transmit all possible information about an observation, or procedure. They are only intended to identify the observation or procedure. The SNOMED code for a name is unique and permanent.

SNOMED CT combines the content and structure of the SNOMED Reference Terminology (SNOMED RT) with the United Kingdom's Clinical Terms Version 3 (formerly known as the Read Codes).

14_{American Medical Association/Centers for Medicare & Medicaid Services. Current Procedural Terminology (CPT) Copyright Notices and Disclaimers and}

Point and Click License. 2011.

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Centers for Medicare & Medicaid Services. Data Submission Specifications Utilizing HL7 QRDA Implementation Guide Based on HL7 CDA Release 2.0

Version: 2.0 Last Modified: July 01, 2010 Available at: https://www.cms.gov/PQRI/20 AlternativeReportingMechanisms.asp#TopOfPageAccessed August 7, 2012.

For information on obtaining the standard, contact: SNOMED International

College of American Pathologists 325 Waukegan Rd

Northfield, IL 60093-2750

http://www.ihtsdo.org

Logical Observation Identifier Names and Codes (LOINC®₎16

LOINC codes are available for commercial use without charge, subject to the terms of a license that assures the integrity and ownership of the codes. The LOINC database provides sets of universal names and ID codes for identifying laboratory and clinical observations and other units of information

meaningful in cancer registry records.

Each LOINC record corresponds to a single observation. The LOINC codes are not intended to transmit all possible information about a test or observation. They are only intended to identify the

observations. The LOINC code for a name is unique and permanent. LOINC codes must always be transmitted with a hyphen before the check digit (e.g., “10154-3”). The numeric code is transmitted as a variable length number, without leading zeros.

LOINC codes are copyrighted by Regenstrief Institute and the Logical Observation Identifier Names and Codes Consortium.

The LOINC database can be obtained from: Regenstrief Institute

1001 West 10th Street RG-5 Indianapolis, IN 46202

RxNorm17

RxNorm is the recommended national standard for medication vocabulary for clinical drugs and drug delivery devices produced by the National Library of Medicine (NML). RxNorm is intended to cover all prescription medications approved for human use in the United States.

Because every drug information system that is commercially available today follows somewhat different naming conventions, a standardized nomenclature is needed for the smooth exchange of information. The goal of RxNorm is to allow various systems using different drug nomenclatures to share data efficiently at the appropriate level of abstraction.

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Centers for Medicare & Medicaid Services. Data Submission Specifications Utilizing HL7 QRDA Implementation Guide Based on HL7 CDA Release 2.0

Version: 2.0 Last Modified: July 01, 2010 Available at: https://www.cms.gov/PQRI/20 AlternativeReportingMechanisms.asp#TopOfPage Accessed August 7, 2012.

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Centers for Medicare & Medicaid Services. Data Submission Specifications Utilizing HL7 QRDA Implementation Guide Based on HL7 CDA Release 2.0

Version: 2.0 Last Modified: July 01, 2010 Available at: https://www.cms.gov/PQRI/20 AlternativeReportingMechanisms.asp#TopOfPage,Accessed August 7, 2012

Each (RxNorm) clinical drug name reflects the active ingredients, strengths, and dose form comprising that drug. When any of these elements vary, a new RxNorm drug named is created as a separate concept.

eMeasure Specifications