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RBRVS体系实施的基础之CPT编码简介 | 远景管理咨询工作室

RBRVS体系实施的基础之CPT编码简介

按照美国法律,从1992年开始涉及到联邦医保(medicare)项目,对医师的支付须采用RBRVS体系。简单的来说,RBRVS是针对诊疗操作项目医师的资源型投入进行支付,而上万个诊疗项目,如果没有进行有效的编码, RBRVS体系就无法实施,因此,诊疗项目的编码是RBRVS体系实施的基础。

CPT 代码的全称是“目前使用医疗流程术语” (Current Procedural Terminology),是一系列描述的术语(term)、指南与识别性的编码(identify code),用于汇报医疗服务与程序的,是为了方便医师、患者、保险等医疗机构交流而形成统一的语言来描述手术、诊断等医疗服务过程的。

为了能够将医疗服务进行相对的标准化,美国美国医疗协会(American Medical Association)从二十世纪六十年代开始,进行编码的制定、修订与编撰工作。1966年形成了第一版的CPT编码,主要涵盖手术类的医疗服务。在美国医疗协会(AMA)下,有专业的编撰委员会(editorial panel)对编码进行维护、修改、删除等维护性工作,编撰委员会(editorial panel)由17个专业成员组成,负责对专业内的编码进行维护。

1983年开始,美国老年医疗中心开始使用CPT 代码对于老年保险患者进行记录和报销。逐渐CPT编码也被商业保险公司所采纳。CPT代码成为医疗系统互相沟通的标准,也成为医疗编码的一个里程碑。1996年”健康保险流通与责任法案”(HIPPA) 的通过强制医疗和相关机构使用CPT编码的上级母编码HCPCS进行医疗信息交流。HCPCS编码最为我们熟知的是其一级编码CPT编码,但HCPCS除了一级编码CPT以外,还包括二级编码。二级编码包括主要包括耗材,假肢,器材等非医生服务的医疗部分。CPT代码和ICD代码很相似,但侧重点和目的不同。CPT编码的目的医疗服务,而不是诊断的结果。几乎美国所有的保险公司都使用CPT代码来对医院、医生服务进行报销。

CPT编码实现了医疗服务相对的标准化、电子化的描述,成为医师、患者、医保之间沟通的最为重要的桥梁。在RBRVS体系研究之初,哈佛大学的研团队从病案(Vignette)从发,深度研究医师在提供医疗服务过程中的特征,在锚定了不同的病案(Vignette)医疗服务的特征,如医师的工作特征、开业成本特征与执业分险特征,研究团队将病案(Vignette)最终与CPT编码对接,形成了整个体系统一的基于资源投入的相对的价值体系(RBRVS),并成为医保直接支付医师工作重要依据与标准。

2021年最新的AMA 的CPT编码,美国Amazon有售,见下链接。

https://www.amazon.com/Professional-2021-Current-Procedural-Terminology/dp/1640160493/ref=sr_1_1?dchild=1&keywords=ama+cpt+professional+2021&qid=1623502863&sr=8-1

作者: 远景顾问

Business consultant, focus on improving people, process and performance.

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