1. Breaking the Code on the Codes
Grant P. Bagley, M.D., J.D.
March 27, 2007
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February 22, 2019
MD*

2. AND USEFUL CODING SYSTEM
2007
CMS WILL ADOPT A FAIR
AND USEFUL CODING SYSTEM
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February 22, 2019
MD*

3. THE WORLD OF CODES CODES ARE NOT NEW CODES ARE SOMETIMES MYSTERIOUS
CODES ARE VITAL
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February 22, 2019

4. WHICH ONE IS THE BIGGER MYSTERY?
Or IS IT
Really?
HCPCS
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February 22, 2019

5. OUR UNIVERSAL MESSAGE TO OTHERS IN SPACE
GOLD PLATE WITH
A MESSAGE FOR
OTHERS SENT INTO
SPACE BY NASA
OUR UNIVERSAL
CONCEPTS--WHAT ARE THEY
SAYING?
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February 22, 2019

6. THE REAL QUESTION IN OUR WORLD
I WONDER IF OTHER
CIVILIZATIONS CAN
GET A HCPCS CODE
FROM THEIR WORK
GROUP NO
I’M SURE IT’S
JUST A LAW
OF NATURE
FOR HCPCS
TO REFUSE
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February 22, 2019

7. THE WORLD OF CODES
DRGs
APCs
ICD9
CPT
HCPCS
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February 22, 2019

8. THE MEDICARE VISION OF CODES
For Medicare and other health insurance programs
to ensure that these claims are processed
in an orderly and consistent manner,
standardized coding systems are essential.
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February 22, 2019

9. CPT CODES IN PARTICULAR
Decisions regarding the
addition, deletion,
or revision
of CPT codes
are made by the AMA.
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February 22, 2019

10. WHAT IS THE ROLE FOR CMS IN CODE DEFINITION?
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February 22, 2019

11. DO CPT CODES WORK? INDUSTRY HAS NO VOICE IN THE PROCESS
THE PUBLIC HAS NO VOICE IN THE PROCESS
CONTROLLED BY THIRD PARTY PAYERS
IN SPITE OF HIPPA--NO UNIFORMITY
Medicare contractors and insurers change code definitions and applications at will
CMS exercises little or no oversight
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February 22, 2019

12. HCPCS LEVEL II CODES FOR DEVICES FOR SUPPLIES
FOR UNIQUE MEDICARE PURPOSES
DRUGS/BIOLOGICS
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February 22, 2019

13. THE HCPCS DECISION TREE
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February 22, 2019

14. CRITERIA FOR A “NEW CODE”
EVIDENCE OF IMPROVED OUTCOMES
“PEER REVIEWED LITERATURE”
COMPARATIVE STUDIES
NOT CLEARLY DEFINED
Doc #
February 22, 2019

15. A DIFFERENT APPROACH FOR THE SAME SERVICE REQUIRES LITTLE EVIDENCE BUT THE SAME CODE
Doc #
February 22, 2019

16. OR A LOWER COST TO GET A CODE?
DO I NEED MORE EVIDENCE
OR A LOWER COST TO GET A CODE? E V I D N C
COST TO THE PROGRAM
Doc #
February 22, 2019

17. ITEMS THAT PERFORM THE SAME FUNCTION MUST USE THE SAME
CODE UNLESS THEY
HAVE PROOF OF
IMPROVED OUTCOMES
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February 22, 2019

18. The MEDICARE Policy Dilemma
WHO WILL PROTECT THE
TRUST FUND?
CODING
PAYMENT
COVERAGE
Doc #
February 22, 2019

19. POLICIES IN CODE CLOTHING
SHARING OF A CODE (REFERENCE PRICING)
DENIAL OF A CODE
CHANGING DESCRIPTION OF A CODE
GENERIC/COMPOUNDING SUBSTITUTION
PRICING
“EXPERIMENTAL/INVESTIGATIONAL” DETERMINATION
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February 22, 2019

20. WHO WILL PROTECT THE TRUST FUND FROM THE WOLF?
Doc #
February 22, 2019

21. EVIDENCE BASED MEDICINE
WHAT DOES IT
PROMISE US?
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February 22, 2019

22. FORMULATE THE QUESTION
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February 22, 2019

23. THE ANSWER FROM MEDICARE PERSPECTIVE---
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February 22, 2019

24. THE MEDICARE TRUST FUND UNDER ATTACK
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February 22, 2019

25. THE FIRST CMS GROUP SAID WE WILL PROTECT THE TRUST FUND WITH COVERAGE POLICIES.
AND THE WOLF
DID STUDIES,
HAD THEM
PUBLISHED
AND APPLIED FOR
AN NCD.
Doc #
February 22, 2019

26. THE SECOND CMS GROUP SAID, WE WILL PROTECT THE TRUST FUND WITH A FEE SCHEDULE.
AND THE WOLF
DEVELOPED COMMENTS
TO THE PROPOSED
FEE SCHEDULE
AND THE FINAL RULE
WAS OK.
Doc #
February 22, 2019

27. BUT THE CLEVER THIRD GROUP SAID WE WILL PROTECT THE TRUST FUND
WITH A HOUSE MADE OF CODES
WE WILL MAKE THIS
HOUSE FROM STRONG
CODES--
HCPCS CODES,
CPT CODES,
ICD9 CODES,
J CODES
K CODES,
C CODES,
XYZ CODES
AND SO THEY DID.
Doc #
February 22, 2019

28. AND THE WOLF CAME TO THE CODE HOUSE…
AND THERE
WAS NOTHING
THE WOLF
COULD DO
BECAUSE THERE WAS NO
APPEAL PROCESS OR WAY
THAT HE COULD
PARTICIPATE IN CODES.
Doc #
February 22, 2019

29. Doc #
February 22, 2019

30. THE EXISTING HCPCS CODE SET
IS POORLY MANAGED AND MAINTAINED
SERVES TO HIDE OTHER POLICY AGENDAS
IS HOSTILE TO NEW TECHNOLOGY
LACKS ADEQUATE COORDINATION
FAILS TO SERVE THE NEEDS OF PUBLIC HEALTH
FAILS TO MEET THE NEEDS OF OTHER AGENCIES
FAILS TO SERVE THE NEEDS OF HOMELAND SECURITY
FAILS TO MEET THE NEEDS OF MEDICA RESEARCH
IS UNRESPONSIVE TO QUALITY IMPROVEMENT
CONTROLLED BY PAYERS ONLY
Doc #
February 22, 2019

31. WHAT NEEDS TO BE DONE USE MODERN TECHNOLOGY
MAKE CODING AS SPECIFIC AS POSSIBLE
PROVIDE A BASIS FOR INFORMATION ABOUT OUTCOMES
INVOLVE ALL STAKEHOLDERS
Public
Industry
Providers
Payers
Government
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February 22, 2019