Create a Custom Code Group in Pega Foundation for Healthcare

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Create a Custom Code Group in Pega Foundation for Healthcare

Description Learn how to create code groups to support multi-faceted transactions in Pega Foundation for Healthcare.
Version as of 8.1
Application Foundation for Healthcare
Capability/Industry Area Healthcare



Healthcare codes lie at the core of all healthcare transactions, such as claims adjudication, clinical management and benefit creation. All aspects of health information are represented by healthcare codes, including but not limited to diagnoses and procedures, service types, provider taxonomy, and patient status. Pega Foundation for Healthcare enables users to create and manage a broad spectrum of codes and coding configurations to support those healthcare transactions. 

In Pega Foundation for Healthcare users can create, edit, and update individual or multiple codes (called code sets) within a wide range of categories, that include such industry standards as the Current Procedural Terminology (CPT®) procedure codes, International Classification of Disease (ICD®) procedure and diagnosis codes, and Health Care Common Procedure Coding System (HCPCS) codes.

Users can also create customized groupings of healthcare codes, called code groups, to support multi-faceted transactions such as claims processing, provider and member management, and clinical care management. Pega Foundation for Healthcare provides the user flexibility to create and edit customized code groups that include codes from a single or multiple code sets. This document articulates the approach for creating a customized code group to support downstream healthcare transactions.  For a business overview on code sets and code groups, please click on the following link and navigate to the Healthcare code group management section in the Pega Foundation for Healthcare Product Overview Guide.

Use case example[edit]

A health plan wishes to create a policy that specifies coverage for home health services. As part of that effort, the plan will use a custom code group to identify which home health services will be covered, and which will be excluded from coverage.  A single code group that is built with codes from multiple service code sets will be used to support the health plan's critical transactions, such as claims adjudication and provider reimbursement.   

Before you begin[edit]

The creation of code groups is dependent on the availability of certain codes within codes sets in the Foundation's code management layer. It is necessary for the codes used to support the above use case to be included in the base code sets prior to creating the custom code group. For the purposes of supporting the use case above, the codes identified below are included in their respective code sets.  For more information on creating and managing code sets, please click on the following link and navigate to the section titled Code manager portal - Code sets use cases, in the Pega Foundation for Healthcare 8.5 Common Codes Solution Business Use Case Guide. Also, please click on the following link to view the Foundation's Current Common Codes Supported File Formats.

Code Set Code Description
CPT 99431 Home visit E&M straightforward decision making
CPT 99342 Home visit E&M medium decision making
CPT 99343 Home visit E&M moderate decision making
HCPCS G0151 Home PT services
HCPCS G0152 Home OT services
HCPCS G0153 Home ST services
HCPCS G0154 Home skilled nursing
HCPCS G0155 Home social work services
HCPCS T1000 Home private duty nursing
HCPCS T1001 Nursing Assessment
ICD 10 Pcs Z51.5 Encounter for palliative care

Process[edit]

In Pega Foundation for Healthcare's Code Manager layer, the user selects the Code groups tab from the top of the screen and clicks on the Create button in the top right-hand corner. The user then selects from the parameters below in the first step of the Create code group workflow. For more information on creating a code group, please click on the following link and navigate to Use case 2.1 - Create code group in the Foundation's Common Codes Solution Business Use Case Guide.

  1. Code group ID: Home Health Services
  2. Code group type: Service
  3. Purpose: All
  4. Product category: Medical

In step 2 of the workflow, the user selects 3 service code types: CPT, HCPCS, and ICD 10 procedure. The user selects the parameters below.

  1. Code type: CPT
    1. Included range: 99341 - 99343
  2. Code type: HCPCS
    1. Included range: G0151 - G0155
    2. Excluded range: T1000 - T1001
  3. Code type: ICD 10 Procedure
    1. Individual included code: Z51.5

In step 3 of the workflow, the user reviews the configured codes and, when satisfied, clicks on the Finish button to complete the workflow. The Foundation automatically creates the custom code group data object and routes the Code group for approval before it is available for use by a consuming healthcare transaction application. For more information on the code group approval process, please click on this link and navigate to Use case 2.2 - Approve or reject code group in the Foundation's Common Codes Solution Business Use Case Guide.

Results[edit]

Upon completion of the Create custom code group workflow, and subsequent approval, Pega Foundation for Healthcare will have instantiated a custom code group that can then be implemented to support healthcare transaction logic in downstream applications.