Flex Code specifying Procedures, Diagnosis and Providers

In addition to the generic behavior of flex code definitions in Oracle Health Insurance, the flex codes in Claims can serve as definition for diagnosis, procedure or provider codes.

A flex code definition for a procedures, diagnoses or provider code system is essentially not different form the generic flex code definition, with the exception that they validate procedure, diagnose or provider codes, instead of flex codes.

Why does Claims use a flex code definition to specify procedure codes?

  • One payer may have to deal with multiple procedure code definitions. For example, the United States has different code definitions for the ICD-9, ICD-10, CPT and NDC procedures. It is quite possible that different procedure code definitions have overlapping codes, so it is imperative that each procedure code keeps track of the definition to which it belongs. For example, code 1234 may be a valid code in both the ICD-9 and ICD-10 procedure definition, but have a different meaning in either definition.

  • Using a flex code definition allows a user to extend a table with a dynamic field that holds a reference to an actual procedure, diagnosis or provider, rather than simply a code. For example, a payer can extend the claim line table with an 'admitting diagnosis' dynamic field. The set of allowable values for this field would then be derived from the diagnoses present in Claims.

  • Validating a procedure code by a through a flex code definition allows a payer to define a specific code format per definition. For example, it can be enforced that an ICD-9 code always consists of between 2 and 4 digits and that the second and third digit are always separated by a decimal point.

There are two peculiarities with regard to flex code definitions that specify a procedure code:

  • The definition only holds two fields: a key field for the code, and a descriptor field for the procedure description. Any additional flex code field usages are ignored by the system.

  • The Flex Code Definition is not linked to the Procedure through a Dynamic Field Usage. Instead, that Flex Code Definition is added to a dedicated Flex Code Set. Once a definition is added to this dedicated set it can automatically be used to define procedures. This dedicated Flex Code Set is specified during an Claims implementation.

The following scenario covers only procedure codes, but the same holds true for diagnosis and provider codes.

The payer wants to set up a new flex code definition for the National Drug Code system (NDC). These NDC codes have a specific format. The code is composed of three sections. The first section specifies the product labeler, the second the product segment and the third the package segment.

Even though NDC codes are composed, the payer decides to use a flex code definition. The reason is that the meaning of the second and third code segments depend entirely on the first part of the code. Therefore, even though an NDC code is segmented, the parts cannot be used separately nor independently.

The payer creates two flex fields:

  • Code 'NDC', Description 'National Drug Code', Length 12, Data type 'Char', Validation 'NDCVAL'

  • Code 'C60', Description 'Generic text 60 chars', Length 60, Data type 'Char'

The dynamic logic validation 'NDCVAL' holds a regular expression that ensures that NDC codes exist in one of the following groupings of digits into segments: 4-4-2, 5-3-2, or 5-4-1.

The flex code definition must consist of two fields (code and description), so the payer creates two new flex code field usages:

  • Field '__NDC_', code 'CODE', display name 'Code'. Key field. Because key is checked this field defaults to mandatory and the display sequence defaults to 0. _

  • _Field 'C60', code 'DESC', display name 'Description'. Descriptor field. The display sequence is set to 1. _

The result is a flex code definition that consists of two fields. In order to make this definition available for procedures, the payer is required to add the definition to the flex code set that designated as the flex code set for procedure codes. This set is marked by a technical flag that is not configurable through the Claims user interface pages. The 'procedure' flex code set is set up and marked as part of the implementation of Claims.

Code Definitions

The payer adds the NDC flex code definition to the flex code set named PROCEDURES. By doing so, the NDC definition becomes one of the available definitions for a procedure code.

The image shows the result of the setup described in this scenario. Each procedure record keeps track of the flex code definition by which it is defined, therefore imposing any validations associated with that definition on the procedure code. A procedure may belong to any one definition that is part of the 'procedure' flex code set.