webinar
Update on Health Care Service Data Reporting Guide
Presented by
Bob Davis
with a special thank you to Ginger Cox
April 14, 2010
Standards Primer
Page 1
ANSI Accredited Standards Committee (ASC) X12N
– The standards organization responsible for most of the
HIPAA mandated transactions (claims, eligibility,
enrollment, etc)
– Development of HIPAA Implementation Guides
• 837- Claims, 834-Enrollment, 835-Remittance
• 837 Health Care Services Data Reporting Guide
– Versions represent October changes
• 4010 – October 1997 – Current HIPAA version (2000)
• 4050 – October 2001 – Many changes made
• 5010 – October 2003 – New HIPAA Version (2012)
• 6020 – October 2009 – Working version for 2 years
Standards Primer
Page 2
• The Health Industry transactions are housed in the
Insurance (N) subcommittee.
• Changes to ASC X12 standards based on identified
industry business needs.
• Public Health Data Standards Consortium and its
member organizations made a HUGE impact on the
ASC X12 standards.
Impact of PHDSC on ASC X12
Important Facts
• The X12 insurance committee now welcomes our
membership and contributions, including
– National Uniform Billing Committee (NUBC)
– National Uniform Claim Committee (NUCC)
• Our message has been heard that Public Health
Reporting systems need to be accommodated in the
standards!!!
• ASC X12N approved 2 versions of the Health Care
Service Data Reporting Guide (4050 and 5010).
– Note: Version 4050 was NOT in synch with HIPAA institutional
claims (837 I) implementation guide.
– Note: Version 5010 is totally in synch with the new HIPAA
institutional claims (837 I) implementation guide.
Health Care Service: Data
Reporting (837)
About 80 data
segments with
many related
data elements
ASC X12 Standards for Electronic Data Interchange Technical Report Type 3
Changes to ASC X12 standards made as
a result of Public Health Initiatives.
• Use of the national standard code list for Race &
Ethnicity code.
• Support for reporting the Present on Admission
Indicator.
• Support for reporting the Language necessary
for patient and provider communication
• Support for reporting ICD-10 diagnosis and
procedure codes.
• Development and maintenance of Source of
Payment Typology.
X12 Standards
• Ownership and Maintenance Process
– Some data elements are supported by X12 (Internal
Value Sets)
– Some data elements are supported by other data
maintenance organizations named by X12 (External
Value Sets)
• Examples
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X12 for birth dates, gender
OMB for race and ethnicity
NCHS and CMS for ICD-10 code sets
PHDSC for Source of Payment Typology
NUBC for present on admission
Purpose of Health Care Service Data
Reporting Guide (837 HCSDRG)
• A HIPAA compatible EDI standard for
reporting hospital discharge data
• Lessen the burden of providers for
reporting by using ubiquitous standards
• Designed for public health organizations
and government entities with mandates to
collect patient data.
Data Elements supported by
the HCSDRG
– Patient demographics (date
of birth, gender, residence,
name, personal identifier,
race and ethnicity)
– Payer Information
– Diagnosis codes (Including
E-codes)
– Present on Admission
Indicator
– Procedure codes (ICD,
CPT, HCPC)
– UB Revenue Codes
– Patient Discharge Status
– Marital Status
– Preferred Language
Spoken
– UB Condition, Occurrence,
& Value Codes
– Service dates
– Service provider
– Attending, Operating,
Rendering, Referring
Provider
– Charges
– Type of Bill (Inpatient,
Outpatient, ED)
– Facility Type
– Admission Type
– Point of Origin (Old Source
of Admission)
– Source of Payment
Typology
Significance of the 5010 Version
• 5010 is the latest ASC X12 approved version
• 5010 is the version of the standard that will be
implemented as part of the next HIPAA mandates to be
adopted in 2012.
• 5010 is a more stable standard as evidenced by the
fewer number of changes between this and future
versions.
• 5010 successfully implemented in New Jersey, using the
837 HCSDRG
Change Specifics
ICD-10 Here We Come!
• ICD-10-CM and ICD-10-PCS will be a HIPAA mandated
in 2013. (Support for this change is in 5010 versions)
• Developed a basic core set of ICD-10 codes for ease in
maintenance. The health care industry owes a big thank
you in particular to Ginger Cox from the California Office
of Statewide Planning and Development and staff from
the National Center for Health Statistics. (Note this work
is part of the 6020 version development).
• The ASC X12N Claims work group (WG2) voted to
approve the core set of ICD-10 codes for all examples in
their implementation guides.
• It should be noted that support for reporting ICD-9 will
remain.
Improvements!
In later versions of the implementation guides there is
considerable work occurring to provide better definitions
for important terms
– Provider Definitions
• Discrepancies between definitions in ASC X12
implementation guides and those of external organizations,
such as the NUBC / NUCC were resolved.
– Service Location
• There was confusion about when and how to report the
service location.
• Again there is an effort to create unambiguous and standard
definitions.
Improvements!
Continued
The situational rules are being further refined to be
consistent across the industry.
– All situational notes common to multiple guides
– Admit Date and Admit Hour
• Discrepancies situational rules in ASC X12 implementation guides
and the NUBC UB-04 Specifications are being resolved.
– Address
• Inconsistencies in the reporting of address information under different
circumstances are being resolved.
The support for needed data elements continues to be refined to
meet changing industry business uses.
– Expansion of the procedure code reporting to accommodate Worker’s
Comp requirements on outpatient claims for professional services.
– Additions to support ongoing demonstration projects. (i.e. support to add
the legacy Medicare Provider Number for institutional and professional
services to support this need)
Version Issues again
Version 5010 (October 2003):
– Version 5010 will be implemented January 2012.
– Changes to the 5010 (errata) will require a public comment
period and will need to be adopted in the Federal Register
before implementation.
– The changes in 5010 are significantly less than what made up
the 4010 version.
Version 6020 (October 2009):
– All 5010 changes will be incorporated into the working version
6020.
– Version 6020 will be on a two-year cycle, starting with February
2010. This schedule will be more predictable for changes within
the X12 industry.
– Version 6020 will use the ICD-10 code set for all examples for
diagnoses, procedures, and external causes of injury and all
examples in the appendices.
– The changes in 6020 are significantly less than what made up
the 5010 version.
HCSDRG Changes
Reporting Guide Changes in 5010 (October
2003)
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–
–
–
Support for reporting ICD-10-CM and ICD-10-PCS
Support for reporting Present on Admission Indicator
Support for reporting up to 12 External Cause of Injury Codes
Support for reporting Race and Ethnicity Codes
Reporting Guide Changes in 6020 (October
2009)
– The Source of Payment Typology will be supported
– The Present on Admission Indicator will be improved
– The Patient’s language for transacting health care will be
supported.
Present On Admission Coding Tutorial
• The recommended values for reporting POA are:
–
–
–
–
–
Y
N
U
W
?
Yes
No
No Information in the record
Clinically Undetermined
Exempt
• Medicare wanted to use POA in the current HIPAA Version –
4010A1. The only place POA would fit in that standard was in the
K3 segment. To differentiate between NO DATA and Exempt in the
K3 string, Medicare decided to use 1 to mean Exempt.
• In the next HIPAA Version (5010) there are only 4 values used to
define POA (Y, N, U, W). Since the 5010 has a designated spot for
POA and only 4 acceptable values, the BLANK would have to be
used to represent the Exempt value.
• In the versions being worked on now (6020), the problem is being
fixed. The 5 POA values would be maintained by the NUBC as an
external code list. In that list, “E” will represent the Exempt value*.
Language – Some Details
Synonyms
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–
–
–
–
–
–
–
–
–
–
–
Patient’s Language
Primary Language
Preferred Language
Preferred Language Spoken
Predominant Language
Principal Language
Patient Primary Language
Patient Preferred Language
Principal Language Spoken
Patient Language Spoken
Care Language
Language Use (this generic name came from X12 data segment LUI)
Definition
– NUBC Definition: The language is the one the patient prefers to use in discussing
with those in the health care community.
Adopted in UB-04 by NUBC – Jan 1, 2011
It is important to note:
Language is a variable of interest in the Meaningful Use Interim Final Rule.
Implementation Issue
HIR 882: Mix of ICD9 and ICD10 for professional claims
•
HIPAA Interpretation Request (HIR): When there is a crossover in service
dates on 837 Professional claim, can we submit both ICD-9 codes for services prior
to 10/1/2013 and ICD-10 codes for services on or after 10/1/2013?
•
Response: X12 is limited to addressing only the technical response to this HIR.
There may be policy impacts related to this issue that are outside the purview of X12.
While it is technically possible to report a mix of ICD-9 and ICD-10 codes, submitters
should be aware that some payer systems may not be able to process both ICD-9
and ICD-10 codes on the same claim successfully. Receivers may have established
business rules that address this issue as well.
•
Discussion: Workgroup discussed why both codes with appropriate qualifiers
cannot be on the same claim. Some feel the service dates or discharge dates would
indicate which codes/qualifiers to use for reimbursement. CMS will require a split of
claims – one in ICD-9 and the other in ICD-10 because it will be clear, especially in
doing the coordination of benefits process. CMS will look into this and see if there is
a requirement to split for payment ease or not (costly process).
The Next New Horizon
Clinical Data
• To better monitor the quality of health care being
delivered, more clinical data will need to be
collected.
• The big unanswered question is how to collect
clinical information and what is the minimum amount
of clinical data necessary to evaluate quality of care.
• The Data Determination Coordination Project (DDCP)
is a collaborative effort between X12 and HL7 to provide
guidelines to answer those questions.
Your Input Needed?
• Where possible, the HCSDRG is harmonized with the
Health Institutional Claim Transaction (837I).
• We need your help to determine if the Public Health
Needs differ from the claim needs.
– Are Payer and Patient Amounts necessary in future versions?
– Are State License Numbers necessary in future versions
because of the mandated use of NPI?
– Should the Reporting Guide support reporting Professional
Services?
– What clinical data elements need to be supported in the
standards?
– What other standards need to be supported for public health
reporting data (i.e. Remittance data {835} for claims data)?
Your Plans for 837 HCSDRG?
We hope you consider using this reporting guide
standard for your EDI process.
– Will this meet your business needs?
– Do you have plans to implement this?
– Are there hurdles to incorporate this?
– Continue to give us feedback at:
http://www.phdsc.org/standards/health-caredata.asp
Those Pesky Acronyms Defined
Acronyms
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•
•
•
•
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ANSI = American National Standards Institute. Formed in 1918, ANSI is defined on its web
administers and coordinates the U.S. voluntary standardization and conformity assessment
system. ASC X12 has been accredited by ANSI since 1979.
ASC = American Standard Committee
CICA = Context Inspired Component Architecture. ASC X12 framework for developing reusable
syntax neutral components that can be expressed in XML or any future standards format.
DM = Data Maintenance (within ASC X12)
DSMO = Designated Standard Maintenance Organization. An organization, designated by the
Secretary of the U.S. Department of Health and Human Services, to maintain standards adopted
under HIPAA. The following organizations serve as DSMOs: ASC X12, Dental Content
Committee (DeCC), Health Level Seven (HL7), The National Counsel for Prescription Drug
Programs (NCPDP), National Uniform Billing Committee (NUBC), and National Uniform Claim
Committee (NUCC).
HIPAA =Health Insurance Portability and Accountability Act of 1996
HIR =HIPAA Implementation Guide Interpretation Request. ASC 12N hosts a portal to provide
information on existing versions of the X12 Implementation Guides mandated by HIPAA. Issues
must be entered into the HIR first. As of Jan 12, 2010, it is open to anyone who wishes to search
the repository for additional information before submitting new requests for a formal or informal
response from ASC X12.
IG = Implementation Guide. It is intended to be compatible, but not compliant, with the national
data standards set out by the HIPAA and its associated rules
Those Pesky Acronyms Defined
Acronyms
•
•
•
•
•
•
RTA = Real Time Adjudication. There are six ASC X12-WEDI Work Groups. They tackle an array
of RTA issues. Those RTA workgroups included: Transaction Business Process Modeling; RTA
Glossary, Communications, Security and Privacy; HIPAA Exception Requests; and RTA
implementation
SDO = Standards Developing Organization. ASC X12 is one of approximately 200 ANSIaccredited standard developing organizations (SDO).
TR3 = Technical Report 3. It addresses one specific business purpose through the
implementation of one or more X12 transaction sets and is used to facilitate uniform
implementation of one more X12 transaction sets and is used to facilitate uniform implementations
within an industry.
X12 = The most widely used standard for electronic data interchange (EDI) in United States and
much of North America.
XML = Extensible Markup Language. It is simple, flexible text format derived from SGML (ISO
8879). It is designed to represent and exchange data electronically.
837 = Health Care Claim. There are three 837’s: 837 Health Care Claim: Institutional; 837 Health
Care Claim: Professional and 837 Health Care Claim: Dental. Another 837 implementation guide
is 837 Health Care Services Data Reporting Guide. It mirrors the standardized data requirements
and content utilizing the 837 Health Care Claim transaction set claims. It is intended for the public
health entities, but it is not intended to meet the needs of all health care services data reporting.
This guide will provide a definitive statement of national reporting standards to permit the
translation of many formats into one common format.
Parting Thought
For a computer system to be a success, you need 2 champions
A program guy
A computer guy
The program guy needs a standard to meet his / her business needs.
The computer guy needs a standard to meet his / her technical needs
The HCSDRG is designed to meet both sets of needs and with your
help, it will evolve to do a better job with every new version
Questions
Parting Thoughts
To Move Us
Forward
Do not get yourself in trouble!
Aim High!
Stay focused on your job
Exercise to maintain good health
Practice Team Work
Rely on your trusted partner to
watch your back
Save for raining day
Rest and Relax!!!
Always smile when your boss is
around
And remember … nothing is
impossible!
Contact Information
Consortium website:
http://www.phdsc.org
Bob Davis
rdavis@nahdo.org
518-456-1735