CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
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CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®), published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

: Procedure Codes - AMA CPT - CMS HCPCS Value Set - XML Representation

Page standards status: Trial-use

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<ValueSet xmlns="http://hl7.org/fhir">
  <id value="AMACPTCMSHCPCSProcedureCodes"/>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: ValueSet AMACPTCMSHCPCSProcedureCodes</b></p><a name="AMACPTCMSHCPCSProcedureCodes"> </a><a name="hcAMACPTCMSHCPCSProcedureCodes"> </a><a name="AMACPTCMSHCPCSProcedureCodes-en-US"> </a><p>This value set includes codes based on the following rules:</p><ul><li>Include these codes as defined in <a href="http://terminology.hl7.org/6.1.0/CodeSystem-data-absent-reason.html"><code>http://terminology.hl7.org/CodeSystem/data-absent-reason</code></a><table class="none"><tr><td style="white-space:nowrap"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td><a href="http://terminology.hl7.org/6.1.0/CodeSystem-data-absent-reason.html#data-absent-reason-not-applicable">not-applicable</a></td><td>Not Applicable</td><td>There is no proper value for this element (e.g. last menstrual period for a male).</td></tr></table></li><li>Include all codes defined in <a href="http://terminology.hl7.org/5.0.0/CodeSystem-CPT.html"><code>http://www.ama-assn.org/go/cpt</code></a></li><li>Include all codes defined in <a href="http://terminology.hl7.org/5.0.0/CodeSystem-hcpcs-Level-II.html"><code>https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets</code></a></li></ul></div>
  </text>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">
    <valueCode value="fm"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status">
    <valueCode value="trial-use">
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom">
        <valueCanonical
                        value="http://hl7.org/fhir/us/carin-bb/ImplementationGuide/hl7.fhir.us.carin-bb"/>
      </extension>
    </valueCode>
  </extension>
  <url
       value="http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSProcedureCodes"/>
  <version value="2.1.0"/>
  <name value="AMACPTCMSHCPCSProcedureCodes"/>
  <title value="Procedure Codes - AMA CPT - CMS HCPCS Value Set"/>
  <status value="active"/>
  <experimental value="false"/>
  <date value="2024-12-18T23:56:31+00:00"/>
  <publisher value="HL7 International / Financial Management"/>
  <contact>
    <name value="HL7 International / Financial Management"/>
    <telecom>
      <system value="url"/>
      <value value="http://www.hl7.org/Special/committees/fm"/>
    </telecom>
    <telecom>
      <system value="email"/>
      <value value="fm@lists.HL7.org"/>
    </telecom>
  </contact>
  <description
               value="The Value Set is a combination of two Code Systems: CPT (HCPCS I) and HCPCS II procedure codes. They are submitted by providers to payers to convey the specific procedure performed. Procedure Codes leverage US Core Procedure Codes composition.

The target set for this value set are the procedure codes from the CPT and HCPCS files.

The Current Procedural Terminology (CPT) code set, created and maintained by the American Medical Association, is the language of medicine today and the code to its future. This system of terminology is the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs. CPT coding is also used for administrative management purposes such as claims processing and developing guidelines for medical care review. Each year, via a rigorous, evidence-based and transparent process, the independent CPT Editorial Panel revises, creates or deletes hundreds of codes in order to reflect current medical practice.

Designated by the U.S. Department of Health and Human Services under the Health Insurance Portability and Accountability Act (HIPAA) as a national coding set for physician and other health care professional services and procedures, CPT’s evidence-based codes accurately encompass the full range of health care services.

All CPT codes are five-digits and can be either numeric or alphanumeric, depending on the category. CPT code descriptors are clinically focused and utilize common standards so that a diverse set of users can have common understanding across the clinical health care paradigm.

There are various types of CPT codes:

**Category I:** These codes have descriptors that correspond to a procedure or service. Codes range from 00100–99499 and are generally ordered into sub-categories based on procedure/service type and anatomy.

**Category II:** These alphanumeric tracking codes are supplemental codes used for performance measurement. Using them is optional and not required for correct coding.

**Category III:** These are temporary alphanumeric codes for new and developing technology, procedures and services. They were created for data collection, assessment and in some instances, payment of new services and procedures that currently don’t meet the criteria for a Category I code.

**Proprietary Laboratory Analyses (PLA) codes:** Recently added to the CPT code set, these codes describe proprietary clinical laboratory analyses and can be either provided by a single (solesource) laboratory or licensed or marketed to multiple providing laboratories that are cleared or approved by the Food and Drug Administration (FDA)). This category includes but is not limited to Advanced Diagnostic Laboratory Tests (ADLTs) and Clinical Diagnostic Laboratory Tests (CDLTs), as defined under the Protecting Access to Medicare Act of 2014 (PAMA).

To obtain CPT, please see the license request form [here](http://info.commerce.ama-assn.org/ama-data-file-request-2020)

The Level II HCPCS codes, which are established by CMS's Alpha-Numeric Editorial Panel, primarily represent items and supplies and non-physician services not covered by the American Medical Association's Current Procedural Terminology-4 (CPT-4) codes; Medicare, Medicaid, and private health insurers use HCPCS procedure and modifier codes for claims processing.  Level II alphanumeric procedure and modifier codes comprise the A to V range.

General information can be found here: [https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo](https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo)

Releases can be found here: [https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets](https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets)

These files contain the Level II alphanumeric HCPCS procedure and modifier codes, their long and short descriptions, and applicable Medicare administrative, coverage and pricing data."/>
  <jurisdiction>
    <coding>
      <system value="urn:iso:std:iso:3166"/>
      <code value="US"/>
    </coding>
  </jurisdiction>
  <copyright
             value="Current Procedural Terminology (CPT) is copyright 2020 American Medical Association. All rights reserved

See information on the use of HCPCS Level I (proprietary and owned by American Medical Association) and Level II codes [here](https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/HCPCS_Coding_Questions)"/>
  <compose>
    <include>
      <system
              value="http://terminology.hl7.org/CodeSystem/data-absent-reason"/>
      <concept>
        <code value="not-applicable"/>
        <display value="Not Applicable"/>
      </concept>
    </include>
    <include>
      <system value="http://www.ama-assn.org/go/cpt"/>
    </include>
    <include>
      <system
              value="https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"/>
    </include>
  </compose>
</ValueSet>