Can ICD-9-CM procedure codes be reported on hospital outpatient claims?

QUESTION: Can ICD-9-CM procedure codes be reported on hospital outpatient claims? If I use HCPCS codes to report hospital outpatient services at the “required” service line level segment for a claim, may I use the ICD-9-CM procedure codes to report hospital outpatient services at the claim level “situational” segment?

ANSWER: NO. ICD-9-CM procedure codes were named as the HIPAA standard code set for inpatient hospital procedures. The ICD-9-CM procedure codes were not named a HIPAA standard for procedures in other settings such as hospital outpatient services or other types of ambulatory services. Hospitals may capture the ICD-9-CM procedure codes for internally tracking or monitoring hospital outpatient services; but when conducting standard transactions, hospitals must use HCPCS codes to report outpatient services at the service line level and the claim level, if the situation applies. Even though an ICD-9-CM procedure code qualifier is available, in addition to a HCPCS code qualifier, at the “situational” claim level segment, the Transactions and Code Sets regulation states that ICD-9-CM procedure codes is the adopted standard code set for hospital inpatient services

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Physician Quality Reporting Initiative (PQRI)

QUESTION: Is the primary diagnosis the only diagnosis that is applicable to the quality measure being reported or will Physician Quality Reporting Initiative (PQRI) consider all diagnoses reported on a claim?

ANSWER: All diagnoses and quality-data line items are considered for Physician Quality Reporting Initiative (PQRI) reporting. There is no requirement to sequence diagnoses into primary and secondary categories for PQRI. Quality-data codes (QDCs) should be submitted for any measures that are applicable to each Medicare Physician Fee Schedule (PFS) claim, as determined by all the diagnosis (ICD-9-CM) and service (CPT Category I) codes submitted on the claim line items for payment. Each QDC should point to one of the diagnosis codes already present on the claim for the payable service. Without a diagnosis pointer on the QDC line item, the line item will be rejected and returned to the provider as unprocessable. The PQRI quality measure specifications identify the combinations of diagnosis and service codes making a claim eligible for each measure. The PQRI Quality Measure Specifications Manual is available in a download from the CMS PQRI Measures.

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