美國老人與社會輔助醫療保險的醫院門診申報以當代手術字詞與健康照護綜合處置分類系統概念探討

Discussion of Current Procedural Terminology and Healthcare Common Procedural Coding System under U.S. Medicare and Medicaid

美國的老人與社會輔助醫療保險中心(CMS)不論住院申報或門診申報都有採用前瞻性的支付制度(PPS)，但在疾病分類上卻使用不相同的編碼體系。我國醫療院所使用的ICD-10-CM/PCS，美國僅適用在住院申報部分。我國健保申報與美國醫療保險申報在門診所使用的疾病分類編碼制度不同，在美國醫院的門診申報採取了CPT及HCPCS的手術處置分類所歸類出的醫院門診前瞻性支付制度(HOPPS)。
本文嘗試對美國CPT及HCPCS的門診手術處置分類進行簡介，並引用美國專業分類師學院所提到的CPT分類碼是醫療提供者做了什麼?、HCPCS分類碼是醫療提供者使用了什麼？而ICD-10-CM分類碼是表示醫療提供者為什麼這樣做及為什麼使用。所以整體而言，ICD-10-CM的診斷分類碼主要是用來辨識病人尋求醫療服務的理由；CPT及HCPCS分類碼是用來識別醫療提供者執行過哪些門診醫療服務。
不論是ICD-10-CM/PCS, CPT, HCPCS的編碼或申報邏輯，均試圖與現狀臨床醫學的發展與趨勢結合。所以未來疾病分類專業人員的持續教育或編碼新知的相互學習，仍是很重要的精進工作且與醫療保險給付的連結性將會更緊密的互動與成長。也就是說，未來我國是否引進導入CPT或HCPCS而形成的醫院門診前瞻性支付制度(HOPPS)，或在現行ICD-10-CM/PCS的編碼邏輯與健保申報都需要更緊密的與臨床醫療發展與趨勢的結合，才能達到以價值為基礎的支付制度。

The Centers for Medicare and Medicaid Services (CMS) adopted a prospective payment system for both inpatient and outpatient reimbursements. However, a different system was used for medical coding. The ICD-10-CM/PCS used in hospitals only applies to inpatient reimbursements in the United States. The major difference between the reimbursements provided by the National Health Insurance (NHI) in Taiwan and CMS in the US is in the claims for outpatient procedures. The claims for outpatient procedures filed by US hospitals follow the CPT and HCPCS coding systems for which a Hospital Outpatient Prospective Payment System (HOPPS) was developed.
This study aims at investigating the procedural coding system of the CPT and HCPCS in reference to the code developed by the American Academy of Professional Coders where the CPT code designates what the provider does; the HCPCS code designates what treatments or procedures the provider uses; ICD-10-CM/PCS designates why the provider does and uses the said treatments and procedures. Overall, the diagnosis/procedure code, or the ICD-10-CM/PCS, is used mainly to identify the reason why patients seek medical services; CPT and HCPCS codes are used to identify which outpatient services have been rendered by the health-care providers.
Regardless of whether the ICD-10-CM/PCS, CPT, or HCPCS is used, the rationale for both coding and reimbursement aims at aligning with current clinical developments and trends. In the future, continuing education or the sharing of new coding knowledge for professional medical coders remains very important for improving and advancement of their work and will become more tightly connected and grow in tandem with the medical reimbursement. In other words, a decision should be made to determine whether the CPT or HCPCS should be introduced in Taiwan to establish a Hospital Outpatient Prospective Payment System (HOPPS) in the future, or whether the coding and reimbursement rationale of the current ICD-10-CM/PCS should be tethered more closely to clinical developments and trends, in order to achieve a more value-based hospital payment system.