Technical Report 35: Procedure Codes in VHA: Use of Inpatient ICD Procedure vs Outpatient CPT Codes

When coding outpatient procedures, the VHA uses only CPT codes. Inpatient care is primarily coded using International Classification of Diseases (ICD) procedure codes, but some inpatient procedures are captured using Current Procedural Terminology (CPT) codes. The VHA is not unique in its coding practices. CPT codes are used throughout the U.S. for coding in outpatient settings and for professional services provided in inpatient settings. The VHA adopted the national coding rules around 2000 for outpatient coding; national standards for coding inpatient care were implemented earlier.

Because of the longevity (~1978 for initial modules) of the Veterans Information System and Technology Architecture (VistA) otherwise known as the VHA’s Electronic Health Record, some VistA documentation predates the adoption of these national standards for outpatient care, you may see some old terms in VistA that imply that the VHA has unique practices, but VHA actually follows the United States coding rules very closely.

See the full document at (Intranet-only: https://vaww.virec.research.va.gov/Notebook/RNB/RNB11-CrowDS-VHA-Procedure-Codes-CY18.pdf).