Update claim-type valueset to reflect industry practice

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    • Type: Change Request
    • Resolution: Not Persuasive
    • Priority: Medium
    • FHIR Core (FHIR)
    • R4
    • Financial Mgmt
    • ValueSet
    • Terminologies - Valuesets
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      The discussion implies alignment of the .type to an interpretation of the US claiming practice while the resource is intended to support a broader suite of use cases. 

      The .type and the .subtype may be used within a jurisdiction profile or profiles, with .subtype values as defined by a jurisdiction, to create that tighter alignment with the practices exhibited within that jurisdiction.

      We suggest placing this type of definition in the Implementation Guide. 

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      The discussion implies alignment of the .type to an interpretation of the US claiming practice while the resource is intended to support a broader suite of use cases.  The .type and the .subtype may be used within a jurisdiction profile or profiles, with .subtype values as defined by a jurisdiction, to create that tighter alignment with the practices exhibited within that jurisdiction. We suggest placing this type of definition in the Implementation Guide. 
    • Celine Lefebvre / MaryKay McDaniel: 5-0-0

      Update the claim types to reflect actual industry practice.

       

      The Institutional definition speaks to ‘typically inpatient claims’.  In our experience, institutional claims typically include inpatient and outpatient claims.  Due to differences in applicable code sets (for example, DRGs and ICD Procedure Codes are relevant only for Inpatient Facility claims), the IG defines two institutional profiles, one for inpatient and one for outpatient.  We recommend defining two Claim Type values for institutional claims. 

                   

      Code Display Definition
      institutional - inpatient Institutional - Inpatient Claims submitted by clinics, hospitals, skilled nursing facilities, and other institutions for inpatient services, including the use of equipment and supplies, laboratory services, radiology services, and other charges.  Inpatient claims are submitted for admissions for which there is an overnight stay. The claims data is based on submission standards adopted by the Department of Health and Human Services (CMS-1450).
      institutional - outpatient Institutional - Outpatient Claims submitted by clinics, hospitals, skilled nursing facilities, and other institutions for outpatient services, including the use of equipment and supplies, laboratory services, radiology services, and other charges.  Outpatient claims are submitted for admissions for which there is not an overnight stay. The claims data is based on submission standards adopted by the Department of Health and Human Services (CMS-1450).

       

      The Professional definition speaks to ‘outpatient claims from a Physician’ but doesn’t speak to inpatient claims from a physician.   The codes don’t speak to the non-clinician suppliers, such as DME, Home Health Care, Ambulance, etc.  We recommend modifying the code, display and description as follows:

       

      Code Display Definition
      professional-nonclinician Professional and Non-Clinician Claims submitted by physicians, suppliers, and other non-institutional providers for inpatient, outpatient and non-institutional services.  The claims data is based on submission standards adopted by the Department of Health and Human Services (CMS-1500).  Claims with CPT (Current Procedural Terminology) codes represent physician services and claims with Level II HCPCS codes represent non-physician services like ambulance rides, wheelchairs, walkers, other durable medical equipment, and other medical services that are not identified by CPT/HCPCS Level I codes.

       

      Pharmacy data is typically provided by retail pharmacies.  Specialty drugs are typically provided by physicians.  To convey that these claims are submitted by retail pharmacies, our recommendation is to modify the code, display and definition pharmacy as follows:

       

      Code Display Definition
      retail pharmacy Retail Pharmacy Claims submitted by retail pharmacies.  The claims data is based on submission standards adopted by the Department of Health and Human  Services defined by NCPDP (National Council for Prescription Drug Program)

            Assignee:
            Unassigned
            Reporter:
            saul_kravitz
            Watchers:
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              Created:
              Updated:
              Resolved: