@Christian_Reich – I’m not sure I understand your last post and how it relates to this thread. Specifically, I was hoping you would send me some examples of G and C codes that would map to RXnorm because I am unaware of any codes that would do so.
Per @Mark_Danese, here is a more complete summary of what HCPCS should be mapped to what tables:
- J Codes mapped to Rxnorm (Drug Exposure table).
- All J Codes are drugs, reimbursed by Medicare.
- Their reimbursement is generally based on the average sales price of the drug itself
- This J Code only represents to drug itself. The administration of the drug is usually billed as an appropriate CPT code on the same claim to Medicare.
- Please see the following article detailing how Medicare reimburses administration codes for chemotherapy (as an example): http://oig.hhs.gov/oei/reports/oei-09-08-00190.pdf
- Example: if you were a physician who paid for the rituximab and administered it to a patient, the physician will bill J9310 for the cost of rituximab and also bill 96413 for the actual infusion (administration) of rituximab. For mapping purposes, the J9310 should be mapped to Rxnorm (aka the Drug Exposure table) and the 96413 should be mapped to the Procedure Occurrence table.
- Q Codes mapped to Rxnorm and possibly Device Exposure table.
- Q codes are temporary codes for new drugs that do not have a J Code assigned to them yet.
- Q codes can change every quarter.
- Some of these codes include skin substitutes and devices (like casts) – I’m not sure if that is considered a device or a drug in CDM.
- If the Q Code is a drug, there would be an appropriate administration code accompanying that drug on the claim. So this Q code should only be considered for the Drug Exposure table.
- G Codes mapped to Procedure Occurrence table.
- Most G Codes are procedure that specifically Medicare covers that does not have a specific CPT code (or HCPCS level I) assigned to it.
- Some G Codes look like “drug” codes, when they are actually codes for drug testing. These codes are in a range from G6030-G6058 (for 2015).
- Please see article for explanation: http://www.mmplusinc.com/news-articles/item/2015-drug-screening-codes
- A set of G codes are actually codes for Physician Quality Reporting System (PQRS).
- The range of codes are from G8000-G8999.
- Please see article: http://news.aapc.com/index.php/2013/02/2013-picks-for-hcpcs-level-ii/
- These codes are specifically used to participate in the extra bonus (or avoid the penalty now) provided by the PQRS. If physicians report these codes on enough patient claims for the year, they get a little bonus or penalty at the end of the year. These codes are used to describe observations about a patient that cannot be captured in regular claims data.
- Example: G Code G8930 indicates that an assessment of depression severity was done at the initial evaluation.
- I’m not sure where those codes belong in CDM but I can definitely say that they are not drug or device exposures. It’s probably best to put them under the Procedure Occurrence table.
- Since we are talking about PQRS, you should also be aware of CPT Level II codes, which are also used for PQRS and also show up in Medicare claims data. Please let me know (or start a new thread) if you guys need help with CPT Level II codes.
- The range of codes are from G8000-G8999.
- The last set of G codes are actually codes for the Medicare Demonstration Project.
- The range of codes are from G9000-G9999.
- Please see article: http://news.aapc.com/index.php/2013/02/2013-picks-for-hcpcs-level-ii/
- Medicare Demonstration Projects are little test sites Medicare sets up with certain providers to determine best outcomes for patients and revenue. Some of these projects could last years. These set of G Codes are specific to providers working under a demonstration project that have services not typically covered under Medicare. I would still consider these codes procedures and should be under the Procedure Occurrence table.
- The range of codes are from G9000-G9999.
- C Codes mapped to the Procedure Occurrence, Drug or Device Exposure table.
- C codes are temporary codes used by outpatient facilities
- C Codes tend to be a mixed bag and I’m not sure how to map these without going through them one by one.
- E, K and L Codes mapped to Device Exposure table.
- K Codes are temporary durable medical equipment codes
- E Codes are durable medical equipment codes
- L Codes are prefabricated (aka “off the shelf”) prosthetic or orthotic devices.
- Note that CPT codes with a range of 29xxx should be mapped to the Device Exposure table and the Procedure Occurrence table because these codes indicate a custom prosthetic or orthotic device was given. Reimbursement for this CPT code includes the work (aka Procedure) the physician had to do to and the cost of the actual device.
If you have any questions, please do not hesitate to ask! I included links in this forum in case anyone was interested.