What are the appropriate resources for storing billing codes in FHIR when not dealing with claims or invoices (R4)?

Question

When creating resources (Conditions, EpisodeOfCare, Encounter) that typically need billing codes (ICD10 and CPT), what is the generally agreed upon schema for storing these codes for entities who are not directly involved in filing claims or invoicing for time spent on a visit?

Using the following workflow as an example:

1. A 30 minute visit is performed for a patient reporting asthma, resulting in an Encounter, EpisodeOfCare, and Condition.
2. The appropriate ICD10 and CPT codes are chosen - CPT 99255 for the overall visit, and ICD10 J45.2
3. The clinic is not directly billing insurance nor the patient, so a Claim or Invoice doesn't seem appropriate as there would be no ClaimResponse nor sending of an Invoice.

A month later, the same patient returns for asthma issues again:

1. A 30 minute visit is performed for a patient reporting asthma, resulting in an Encounter, EpisodeOfCare, and Condition.
2. After further evaluation, the asthma is more severe than originally diagnosed, and an ICD10 code of J45.5 is chosen. CPT 99255 is chosen again.

For CPT codes, I would think stamping the Encounter makes the most sense, as the CPT is directly associated to the visit. Once that visit is finished, it shouldn't change.

However for ICD10 codes, I'm not certain. If the Condition or EpisodeOfCare itself is stamped, we're overwriting the previously used ICD10 code with a new code. If that patient's chart is ever audited, it could appear that any labs ordered for the Condition/EoC were ordered with the wrong ICD10 code.

Stamping the Encounter also doesn't make sense to me for ICD10 codes, as a single visit could have resulted in multiple Conditions/EoCs being addressed, and each Condition could have its own primary ICD10 code.

The only solution we've considered is duplicating the Conditions as snapshots when the visit is finished, associating the ICD10 codes to those snapshots, and referencing those for any billing information for the visit. The original Conditions are left alone and do not contain any billing information.

Are there any cleaner solutions to this?

Answer 1

If the focus is tracking billable costs prior to creating a Claim or Invoice, you should look at the ChargeItem resource. However, for something like ICD10, Condition is generally the correct place.

Conditions can evolve over time. However, references to a Condition can be version-specific. That allows you to know exactly what version of the Condition drove a particular action. (This, of course, does require the system in question to be able to manage tracking versions of the Condition resource.)