Washington, D.C.
The Subcommittee on Standards and Security of the National Committee on Vital and Health Statistics had a public meeting on June 26, 2001, at the Renaissance Hotel in Washington, D.C.
June 26, 2001
The Subcommittee on Standards and Security met on June 26, 2001 to review the completion of the designated standards maintenance organization (DSMO) fast track change request process and letters to the Secretary: one addressing what the DSMOs recommended; the other focusing on general industry readiness and what HHS needs to do to support implementation.
Overview of DSMO Process and Results of Fast Track for Transaction Standard Changes Needed to Assure Industry Compliance. Margaret Weiker; EDS, chair
Ms. Weiker reported on the completion of the DSMO fast track change request process. Some 231 change requests were processed. Fifty-two change requests were appealed, 14 were subsequently withdrawn. Some 32 of the remaining requests were upheld; six denied. The final tally was: category A – 67, category B - 21; category C - 38, category D - 85, category E - 10, category F – 6, and category G/H - 0.
Ms. Weiker submitted and reviewed a list of 57 Category A change requests the DSMO asks to be incorporated into a Notice of Proposed Rule Making (NPRM). Members noted that HHS had to take a careful look at some items and that the DSMO organizations needed to make sure everything was accurately described. Dr. Cohn asked for Gary Beatty to do the final review over the next several weeks and for the Executive Committee to forward X12’s final modifications. The Subcommittee will ask for the NCVHS Executive Committee’s approval with modifications at the August meeting.
Agenda Item: Letter to the Secretary on HIPPA Implementation
The Subcommittee completed the transmittal letter to the Secretary for the change requests the DSMO asked to be incorporated into an NPRM, addressing what the DSMOs recommended and indicating that the Committee was aware of many code set developers’ concerns and intends to hold hearings later this year. Meanwhile, they advised code set maintainers to continue discussions with DSMOs and other mandated or approved code set developers.
Discussion
The Subcommittee discussed the pay and chase and other issues. The Office of General Counsel determined subrogation was not designated as a HIPAA transaction or a required standard. Members noted an NPRM could be issued, if appropriate changes were made to the X12 set of transactions. Subrogation could still be done using individual versions of the 837. Members also noted the need to clarify the mammography certification number.
Dr. Cohn acknowledged receipt of several letters asking for an extension or delay of two years. He suggested the group reflect on these requests as they considered the letters to the Secretary. Mr. Blair added that the Department had been asked to look at S-836, and found both the Senate and House bills impossible and unworkable. Without standards for transactions to comply with, the Privacy Rule would be “gutted.” The sequence of rules HIPAA foresees coming out over a 10-20 year period would be cut off and no one would have to comply with any future rule. The Congress had been given the information, and the Department was providing technical assistance. The Subcommittee decided to discuss this along with the letters tomorrow with the full Committee.
Agenda Item: Letter to the Secretary on HIPPA Implementation Recommendations
Members went through a draft of their earlier comments on industry readiness, further defining their recommendations to the Secretary, issues coming forward from the DSMO appeals process, and actions HHS must take to support implementation. Explicit examples were identified of a “schedule of interim deliverables/requirements”: (1) doing the claims and remittance advice first, and delaying the other transactions, (2) having all the transactions ready by a specified date, but allowing additional time for implementation and testing with trading partners, and (3) implementing all the transactions on a specific date, but allowing the process to be delayed for code sets and identifiers. And the recommendations were amended to clarify that the Committee doesn't support a delay and particularly opposes open-ended delays such as that found in S-836.
Both letters were brought forward for approval by the full Committee at the next day’s meeting and are available on the NCVHS website: ncvhs.hhs.gov.
June 26, 2001
Dr. Cohn convened this meeting of the Subcommittee on Standards and Security and thanked Ms Weiker and Ms. Ward for being available over the phone.
Overview of DSMO Process and Results of Fast Track for Transaction Standard Changes Needed to Assure Industry Compliance. Margaret Weiker; EDS, chair
Ms. Weiker reported on the completion of the DSMO fast track change request process. Some 231 change requests were processed. Fifty-two change requests were appealed, 14 were subsequently withdrawn. Some 32 of the remaining requests were upheld; six denied. The final tally was: category A – 67, category B - 21; category C - 38, category D - 85, category E - 10, category F – 6, and category G/H - 0.
Category A is modifications necessary to permit compliance with the standard/law. According to HHS, necessary items include: 1) something in the adopted standard or implementation specification conflicts with the regulation, 2) a required but non-existent data element or code set, 3) an omitted data element or code set critical to the industry's business process; 4) a conflict among different adopted standards; and 5) an internal conflict within a standard implementation guide.
Category B is modifications classified as additions or deletions of data elements, internal code list values, segments, loops; changes in usage of segments, data elements, internal code list values; changes in usage notes; changes in repeat counts; changes in formatting notes or explanatory language outside category A.
Category C is maintenance of items that do not impact implementation of the transaction. Maintenance items require no further DSMO action and follow the Standard Development Organization’s (SDO’s) process.
Category D items require no change: implementation guides already meet the need requested or the request was not substantiated. Submitters may follow up for further action. Category E items require follow up by the HHS in regard to the final rule. Category F items were withdrawn by submitters during the business analysis phase. Category G items have been appealed: either a collaborating DSMO or the originator does not agree with the outcome of the business analysis phase. Category H items require additional industry comments to determine consensus.
Ms. Weiker submitted and reviewed a list of 57 Category A change requests the DSMO asks to be incorporated into an NPRM.
Request 113 asked to replace NCPDP batch standard version 1.0 with version 1.1. The DSMO recommended the HIPAA regulations for the Transaction and Code Sets be revised to substitute batch 1.1. Members noted that most requests, including item 113, required an NPRM.
Request 114 referenced removal of all national drug code qualifiers (NDC) from the SV2 segment of the institutional health care claim implementation guide. Ms. Weiker clarified that this would be allowed, but not required; someone already using NDC would not have to revise his or her system. Dr. Nachimson explained they were basically retracting the standard for drug coding for anything except retail pharmacists. The implementation guide's solution, as proposed by X12, allowed J codes supplemented by NDC codes, giving people the opportunity to use either. Payers will determine how they pay. Dr. Cohn noted this was already being handled by an NPRM and probably didn't need to go forward to the Secretary. Dr. Zubeldia expressed concern that the DSMO response didn't include changes in the implementation guide. Ms. Weiker said none of the responses went into “nitty-gritty” details; the SDO dealt with the detailed technical changes. Members agreed that HHS needs to work with X12 to make sure the NPRM and the technical solution are in sync and there is continuity between the implementation guide and the changes.
Requests 115 and 118 asked for the home infusion code set (HEIC) to be adopted. The DSMO’s response is not to recommend HIEC codes for inclusion in the standard code set now, but to strongly encouraged the National Home Infusion Association to try to add their codes during August’s CPT, HCPCS and HIEC meeting focused on home infusion. The qualifier referencing the HIEC codes will be retained in the implementation guides with the following note: "This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property & Casualty claims/encounters that are not covered under HIPAA."
Dr. Zubeldia suggested that this code set might be allowed for use under HIPAA: if the code set for the HIEC has not been adopted by the Secretary as a standard, it was up to the implementation guide to allow or disallow. Dr. Nachimson countered that the Secretary adopted for medical procedures and diagnosis certain code sets and those were the only ones that could be used. In the case of NDC, they retracted any standard for drugs; therefore it fell back to the implementation guide. But as long as a code set is specified for a particular data element and for procedure codes and diagnosis codes, only those code sets can be used. Mr. Blair observed there were broader purposes; it might be more appropriate to say HIPAA did not recognize it. Dr. Cohn clarified that the HIEC is only procedure codes for home infusion services and is not among those mentioned in the final rule. Dr. Braithwaite noted that HIEC was intended to be used in the same place as CPT and HCPCS codes in a procedure slot, the line item, and HIPAA currently does not allow that. It is not an accepted standard for that particular data field. Dr. Cohn remarked that it is a code set that has substantial use, but this was not the time or place to second guess this decision. They needed to accept the DSMO response. But they also needed to indicate to the Secretary their intention to look further into these issues later this year or early in 2002.
Ms. Ward explained that the basis for their recommendation was that before they recommend or adopt an entirely new code set, they needed to make sure all other possible avenues for meeting these codes have been tried.
Request 127 was to use UB-92 condition codes rather than the special program indicator codes in the 837 implementation guides. Asked if this was an issue where the 837 professional and institutionally were diverging, Ms. Ward said the information was expressed through use of the data element in the 837 professional and through use of a condition code, which is an external code set in the 837 institutional. She reported they had discussed the issue of the implementation guides diverging; individuals and X12 had raised concerns about expressing data via external codes versus data elements. Ms. Ward recalled yesterday’s discussion about the data dictionary and defining usages. She said the real issue was that the data could be represented two different ways: as an element and as a code. That was what the COs agreed to.
Dr. Braithwaite explained that using an external code set to express multiple concepts was a way of compressing the implementation guide, but it also transferred control of codes and conditions to, in this case, the NUBC rather than the DSMO and its rulemaking process.
Ms. Greenberg noted that in moving to a condition or a value code with newborn birth weight there was agreement not to collect it in the professional guide--moving from an element hadn't created a difference between the guides. In this case, it did, which had its pros and cons. She also noted it wasn’t clear which changes were the results of the appeal process and which were agreements reached in the original DSMO. Ms. Weiker said the vote was unanimous. If anything was contentious at the beginning, it was worked out. Maybe they all weren't happy with it, but they agreed and were doing it. Dr. Nachimson noted that the fast track report was available to everybody and contained the history with all the requests appealed and the final responses.
Dr. Cohn said he wasn’t going to second guess the group at this point. He had mulled over the many issues between data elements and code sets and there was no perfect answer. As they went forward, they needed to make sure there was a balance in terms of what went in the code sets and what became a data element.
Ms. Weiker said several of the DSMOs got the impression with the last hearings that the Subcommittee felt anything that made cross walking easier would be beneficial. She pointed out that the UB92 paper claim forms had no special field or special program indicator code; but on a HCFA 1500 there were multiple fields to identify what was indicated in a code value. That was something they considered in looking at the external code. Dr. Fitzmaurice remarked that, pushing it, in an ideal world the UB02 would have code sets rather than specific variables for special programs. Ms. Greenberg replied it will. Dr. Zubeldia observed that, when the code sets incorporate rules about when it is appropriate to use the code, one runs into an implementation guide for the code sets. Ms. Ward commented that perhaps the code set maintainers needed to do what the SDOs had done and get accreditation establishing that their processes and procedures were in place. Some people were concerned that changes to these code lists needed to be decisions of a group larger than just the code set maintainer.
Dr. Cohn noted it was important to have as much compatibility as possible between paper and electronic submissions during this transition period, which might exist a long time. He urged everyone to be aware of Dr. Zubeldia’s observations about code sets and data elements. Many of the code sets had guidelines, but it got “mucky;” there wasn’t even a clear definition. He noted they would get into terminologies and code sets later in the year.
Request 128 is to remove usage requirements for a variety of provider information at the service line level on institutional claims. It is situational and the requester wanted it marked “Not used.” The usage note is being changed to “Required when line level provider information is known to impact adjudication.”
Dr. Braithwaite noted hospitals were worried that the payers could force them to use or keep line level provider information. This allows them to only do so when it affects adjudication. Ms. Greenberg added that it was up to the insurers to inform them. Dr. Zubeldia raised a technical question. Possibly the information at the line level was not supposed to be sent unless it was different from the claim level. Removing the required when the provider information was different implied it should be sent at the line level when it could impact adjudication, even though it might be the same as at the claim level. Dr. Braithwaite clarified that the provider information at the line level was always different in an institutional claim. This said it only needed to be sent when it made a difference
Dr. Zubeldia suggested including additional explanation of why this is inconsistent with the rest of the instructions in the guides. Ms. Ward noted those recommendations were developed by the work group in X12. Nearly 100 people attended the meeting every day and the solutions were all but done. If Dr. Zubeldia had an issue, there could be a comment to the NPRM. Dr. Zubeldia said he would take care of it within X12. Noting that the DSMOs had gone through a very involved process, Dr. Cohn said the intent wasn’t to second-guess the modality. Particular issues needed to be brought forward to HHS. They could send a letter to X12, but it might be late for this implementation guide. Ms. Ward said Ms. Weiker’s objection was well taken. It could be a comment to the NPRM.
Dr. Braithwaite pointed out that this was a case where the provider couldn’t fill everything out without having instructions or knowledge about who it was being sent to. The SDOs had been incredibly good about trying to maintain the philosophy of provision; it was virtually impossible in today's world to do that, but they kept moving in that direction.
Request 139 was to remove the provider taxonomy usage requirement from the professional implementation guide. After considerable discussion with the industry (and as a result of input on the Washington Publishing Company Web site), the DSMO agreed to change the requirement to situational. The situation is: "Required when adjudication is known to be impacted by provider taxonomy code."
Request 200 was to remove the taxonomy code usage requirement from the attending physician, operating physician, other physicians, referring physician, specialty information refer for the UB92 institutional. The change was identical to 139. Dr. Cohn remarked that this was a contentious issue for Medicaid and others, but also a good solution. He noted Dr. Braithwaite’s comment that it wasn’t a perfect world. Dr. Fitzmaurice observed the provider had to know whether to put the information in. Ms. Weiker suggested they would find from an implementation perspective that the payers and providers had that dialogue. She reminded them that other payers besides Medicaid needed this. Dr. Braithwaite said he thought it was a good resolution to a difficult problem that would change as they moved forward, but for now was probably best.
Request 146 (Related Causes Information Related Causes Code and State Code) was to remove the code for “abuse” and “another party responsible” from related information. The code value for “abuse” will be removed; the code value for “another party responsible” remains.
Request 147 was to remove the special programming codes (code values - 02,03,05,07,08, and 09) that are also condition codes on the institutional claim and not captured for professional claims. A note "Required for Medicaid only" was added.
Requests 148, 149 and 150 were to have the order date, referral date, and estimated date of birth that are not currently collected for professional claims and reported to payers removed from the 837 guide. They will be removed.
Request 151 was to remove the disability begin date requirement for claims involving disability from the 837 professional guide. A Segment Note, "Not required for HIPAA but may be required for other uses," will be added.
Request 154 was to make the emergency indicator (there is no clear industry definition) not required. The DSMO response was to clarify the definition (NUBC manual): the patient requires immediate medical intervention as a result of severe, life threatening or potentially disabling conditions. Usage of SC109 will be situational. Ms. Weiker clarified the request applied only to the institutional claim. Ms. Fyffe noted it got into the quagmire of managed care, reasonable persons, and the patient bill of rights--and was both needed and controversial. Ms. Greenberg commented that on the UB92 there was a place to capture what the patient thought was happening. Dr. Braithwaite noted many people use the emergency room as their primary health care.
Request 157 was to add a pound qualifier to the 837 professional guide and a note for reporting Patient Weight for Medicare DMERC CMN's. Both were added.
Request 159 was to change elements currently used on the dental claim "at the discretion of the submitter" from “Situational” to "Not Used" in order to discontinue use of local codes. The DSMO recommended adding loops to the implementation guide to support the designation of assistant surgeon.
Request 161 was to make the ethnicity code values the same as those required by the Federal Government. Additional matching codes will be added. Members noted that the standard had been changed for the 837 to allow the OMB code set. Ms. Ward said the long-term solution was to have all the external code sets indicated by the CDC.
Request 167, a non-controversial item, was to change a monetary amount field in the 278 request for review and response to situational.
Request 171 was another non-controversial request for the 834 to provide the ability to send a primary care physician number.
Request 172 added an additional code value and a note to allow tie back to the 834 guide in order to tie driver IDs together.
Request 177 was an errata issue rewording for any particular code in the NDA statement.
Request 178 was to remove the requirement for anesthesia modifying units, which were already in CPT and HCPCS and didn't need a special field. A statement was added and the QTY will be removed. Dr. Zubeldia remarked that modifiers P1 to P5 listed in that QTY were not listed in the HCPCS or CPT list of modifiers. Removing the QTY left P1 through P5, which were used extensively, with nowhere to go. Dr. Cohn noted this was an issue that required further investigation by the Secretary.
Request 184 was to remove the requirement for segments that carry the spinal manipulation information. The change will be made to the 4010 implementation guide and the note revised to state this segment is only required on Medicare Part B chiropractic claims.
Request 191 was to remove the requirement for measurement of newborns from the 837 institutional guide. The NUBC added value code 54 to handle reporting of birth weight on newborn claims and encounters. The requirements in PAT07 and PAT08 will be removed.
Request 194 was a request to remove related causes codes collected elsewhere in the institutional guide and express them in code sets. The DSMO recommended removing the requirement from the 4010 Implementation Guide.
Request 195 was a similar request to remove the special program codes collected elsewhere in the professional guide and express them in code sets. The DSMO recommended removal.
Request 202 was to remove the requirement for referring physician from the 837 institutional guide. The DSMO concurred.
Request 205 was to remove the note to indicate using date of service for the range of dates through which the drug will be used and retain it to indicate the date the prescription was written or otherwise communicated by the prescriber. The DSMO recommended include the changes in the 4010 implementation guide.
Request 209 was to add a REF segment for the prior authorization number to the 837 dental. X12 will add the REF segment.
Request 210 was for a way to reference attachments for data needed, but not supported, in the 4010 278. X12N will add the paperwork segment.
Request 212, an errata request, was to clarify the language in the 277. X12N Work group agreed the corrections would help implementers with transaction pairing.
Request 216 was another errata item correcting the payer claim identification number segment note.
Request 231 was for a qualifier for NUBC codes on the 278 authorization on revenue codes. X12N will add NU as a code list qualifier code.
Request 234 will allow a placeholder to identify the provider id.
Request 238 identifies changes in the 276/277 implementation guide already referred necessary to achieve industry compliance. The current version will be corrected.
Request 239 provides a provision in the 837 dental claim for reimbursable sales tax.
Requests 243 and 244 were errata requests for line level pricing and repricing information. A repricing organization identifier was added.
Request 245 was another errata item for indicating whether one was submitting a home health original or subsequent (HCFA-485 and HCFA-486). Dr. Zubeldia noted that the response mentioned both a code 1 and a code 2 for the 485, 486 and for 486 only. He pointed out that the X12 solution was changed in St. Louis and did not include a code 1 combining both, but repeated the segment. The language needed to note that X12 would deal with the problem.
Requests 247 and 248 (duplicates) modify the segment note for a mammography certification number to use "when mandated by legal or contract requirements,” extending it beyond Medicare.
Request 250 adds a value note "required for anesthesia claims" on the 837 Professional
Request 253 was another errata issue concerning codes in the NDA statement.
Request 255 was to correct the note for purchase services on the 837 professional
Request 256 was to change usage of purchased service provider name to “situational.”
Request 276 was to make the date last seen on the 837 professional situational (required when Medicare B claims involve services).
Request 282 was to remove the requirement for segments that carry the initial treatment spinal manipulation category. The change will be made to the 4010 implementation guide and the note revised to state this segment is only required on Medicare Part B chiropractic claims.
Request 284 allowed additional code value to be used in the 835 guide related to pharmacies.
Request 287 was to add a new situational segment to the 4010 professional guide to support the business need for rental and purchase price information for durable medical equipment. X12 will determine the best technical solution.
Request 288 was to change usage to “situational” and add a statement note to the Institutional 837 excluding claims or encounters for religious, non-medical claims in the hospital from principal, admitting, E-codes and patient reason for visits diagnosis information. Dr. Zubeldia pointed out that with that wording diagnosis could not be reported on lab claims; the language had to be changed.
Request 289 added additional values for EPSDT. Dr. Zubeldia cautioned that X12's final solution was different. The DSMO needed to double check.
Request 304 corrected an error that allowed more than one subscriber in each area where they can be identified in the current X093 implementation guide.
Request 316 was to allow enrollment based upon a qualified medical court support order. X12N agreed the change was critical to implementation. A note was necessary to identify how a sponsor could identify this information on an 834 transaction.
Request 320 was to add comments for the purchase service amount regarding acquisition costs for lenses on a vision claim. X12N will add comments and recommended including this in the 4010 implementation guide.
Request 348 was to remove the requirement for a pregnancy indicator from the institutional guide. NUBC replaced the data element with a new condition code that in part reads: “Required when mandated by law. The determination of pregnancy should be completed in compliance with applicable law." Ms. Weiker noted the indicator remains a data element in the professional guide.
Requests 349 and 350 were to remove product or service ID qualifiers not adopted under HIPAA from the professional and institutional guides. The N1, N2, and N3 will be removed. The qualifier (IV) referencing the HIEC codes will be retained in the implementation guides with the same note as in requests 115 and 118.
Request 356 was for a rule or algorithm for the correct taxonomy code to be reported in a PRV segment when a provider or institution operates under multiple taxonomy coded. The DSMO changes are similar to request 139.
Request 364 is for a valid qualifier to report the patients weight for DMERC CMN's or EPO claims to Medicare in the Implementation Guide. DSMO responded that patient weight in pounds (See item 157) should be added with a note, "Required on claims/encounters involving EPO (epoetin) for patients on dialysis and Medicare Durable Medical Equipment Regional Carriers certificate of medical necessity (DMERC CMN).
Dr. Zubeldia questioned that the patient weight would be required on all DME claims. Members noted that HHS had to take a careful look at items 157 and 364 and that the DSMO organizations needed to take one last look to make sure everything discussed was accurately described. Ms. Weiker said she would point out Dr. Zubeldia’s observations and Gary Beatty would verify the accuracy. Dr. Cohn remarked that they voted on Thursday, but it wasn’t reasonable for Mr. Beatty to respond in two days. Probably they would approve it with modifications at a meeting of the Executive Committee in mid-August, asking the Executive Committee for final agreement. Dr. Zubeldia noted the X12 work group was determining the option for a few items. Those could come in a subsequent letter. Ms. Trudel suggested that the letter to the Secretary could raise them, saying to the extent the solution was understood, they agreed--but some cases might need more details. The DSMO would recommend what they wanted to; they weren’t there to edit. What they needed to be concerned about was policy issues where they wanted to go on record. Dr. Braithwaite pointed out it would be the final X12 document, the implementation guide that was incorporated, by reference, into the NPRM. If the policy was okay, they didn't have to worry about X12 language; that would be put out by the NPRM. Dr. Zubeldia said his concern was about cases where there was a discrepancy between the X12 guide that would be part of the NPRM and the recommendations from the DSMO.
Dr. Cohn asked that Mr. Beatty do the final review over the next several weeks and that the Executive Committee forward X12’s final modifications. The Subcommittee would ask the NCVHS Executive Committee to decide on further modifications and approve them.
Request 366 was an errata request concerning the J and NDC codes. Dr. Cohn noted it was consistent with earlier discussions.
Request 384 was to eliminate N2 segments for spill-over of names longer than 35 characters in the 837 professional. The DSMO recommended to remove all N2 additional name information segments from the 837P, 837I and 837D guides.
Request 386 was to remove the requirement for vision claims/encounters involving replacement lenses or frames. X12 will change the note.
Request 409 was to add condition indicators to the 278 implementation guide regarding the condition of a patient. The DSMO recommended including them in the 4010 implementation guide. HL7 will continue attachment work.
Request 417 was to synchronize some of the eligibility code values in the 270 and 271 4010 Implementation guide.
In addition, the members reviewed category E change requests that HHS needs to consider for incorporation into the NPRM, beginning with:
Request 134 was to allow the 837 dental to be used for dental pre-determination.
Requests 223 and 224 were to gain more time for J Codes and were disregarded.
Request 228 was a correction, amending the current final rule to replace the NCPDP telecom version 5.1 and batch version 1.0 for remittance device and payment with the X12N 835. The DSMO responded that HHS would address this policy issue.
Request 347, another policy issue, was summarized by Dr. Cohn. Based on work with a cross section of health care organizations, it was clear that the current sets of codes did not cover all procedures and diagnosis and due to the evolving nature of health codes, there would always be a problem that pertained particularly to certain specialties or emerging areas. The requester understood that the standards organizations were working to address these issues and reduce the scope of the ongoing problem. Nevertheless, new and evolving procedures and therapies will always raise this concern. The requester recommended a temporary code that can be used for a fixed period of time with commitment to due diligence and having the procedures or diagnoses added to a code set. The DSMO responded that neither they nor the X12 implementation authors had the authority to include any non-designated medical codes or code sets in the HIPAA implementation guides. X12N recommends that the requester work with the maintainers of the designated medical code sets. Ms. Ward said that they would probably have a discussion about HIEC and other codes to explain that they didn’t believe this was within the DSMO’s or X12's area of responsibility.
Request 361 noted the modification to utilize the NCPDP Batch Standard 1.1 for use with various retail pharmacy related transactions (Request 113) and asked for further comments specifying the use of NCPDP 5.1 transaction contents and formats to make the specification unambiguous. The DSMO responded that HHS would issue a notice soon.
Request 408 had to do with Medicaid programs and confusion over encounter data. Medicaid agencies had their managed care plans reporting encounters to them. The DSMO found this out of the scope of the HIPAA transactions: an encounter is a transaction from the provider to the payer. Dr. Nachimson said a FAQ would be out soon.
Ms. Trudel said the only pertinent appeals denied were the alternative link codes (request 137) that was handled in request 347 and the Medicaid request 296. Mr. Blair said he was confused by the description indicating a lack of detailed information about the alternative codes. NCVHS had that information. Ms. Weiker said the DSMO never got it. Ms. Ward said their primary recommendation had been that the submitter needed to work initially with HCPCS and CPT. There was no documentation of that conversation with the other code set maintainers.
Dr. Cohn suggested the Subcommittee needed to say in the letter of transmittal that they were aware of many code set developers’ concerns and intended to hold hearings later this year. Meanwhile, they advised code set maintainers to continue discussions with DSMOs and other mandated or approved code set developers. Ms. Weiker urged them to reinforce the DSMO’s statement: requesters should work with already established main code set maintainers who would help the DSMO understand their conversations.
Asked about HCFA’s view on alternative billing codes, Ms. Trudel replied that many codes might not even be Medicare-covered services. Existing, well-established code sets were the appropriate way to go.
Noting a similar situation with the physician codes and how to properly code eyeglasses, Dr. Zubeldia pointed out this will happen with other concepts. Ms. Trudel clarified that the ground rule for HCPCS codes was it had to be a service in use and covered by someone. Ms. Greenberg remarked that someone might want information about some thing that didn't get paid on an itemized basis. Mr. Blair said it was a bit of the-chicken-or-the-egg. He queried whether the alternative link ABC codes might be the right codes to cover those services.
Dr. Cohn noted they still had to come up with wordsmithing to “unfold” this document. And there were likely to be further technical changes coming forward from the DSMOs. Dr. Nachimson suggested that perhaps the recommendation to the Secretary would be to assure that the addenda, which will be in the proposed rule, were consistent with the DSMO recommendations.
Dr. Cohn said the letter would be public once the Committee approved it; Ms. Weiker and Ms. Ward would get copies quickly. He thanked them both for taking time out of busy work and vacation days.
Agenda Item: Letter to the Secretary on HIPPA Implementation
Dr. Cohn began by reading a working draft of the transmittal letter. Dear Secretary Thompson: As part of its responsibility under HIPAA, the NCVHS provides advice to you regarding standard electronic transactions and code sets adopted under HIPAA. NCVHS has recently reviewed its first recommended set of changes to these standards as recommended by the DSMOs. The DSMOs are a set of organizations that have been designated by the Department to modify the standards based on industry input.
This first set of changes was produced by the DSMOs under a fast track process that the NCVHS requested to expedite these changes. This process required the DSMOs to do their review and analysis work in a compressed time frame, so the changes could be made to the standards through the first year after adoption and in time to assist with additional industry implementation. The DSMO representatives responded to the NCVHS request in extraordinary fashion, devoting substantial time and effort to meeting our deadlines. They are to be highly commended.
The NCVHS has also reviewed the DSMO recommendations for changes to the standards. We advise you to accept all of these changes and begin the regulatory process to adopt these changes as part of the standards. In addition, we urge you to expedite the process so that these changes can be part of the implementation process for health plans, providers and clearinghouses as soon as possible. We recommend the final rule implementing these changes be published no later than January 31, 2002.
We appreciate the opportunity to provide you with this advice.
Dr. Cohn noted additional items for the letter had come up in discussion. They needed to advice code set developers to work with DSMOs and other developers on code set issues. NCVHS plans to address gaps and broader code sets and terminologies issues later this year. Ms. Greenberg added they had to acknowledge that the current sets of codes did not cover all procedures and diagnoses. Ms. Trudel suggested that the Subcommittee endorse the DSMO position that, as a first step, interested parties collaborate with DSMOs and code set maintainers to assure their needs can be met.
A fourth paragraph was added. It is clear that the current HIPAA code sets do not cover all procedures and diagnoses. This will always be a problem due to the evolving nature of health care. Where gaps have been identified, we endorse the DSMOs position that requesters work with the maintainers of the currently designated code sets to address these gaps before new code sets are considered. We are planning to address these and broader issues related to code sets and terminology gaps at hearings some time in the late fall or winter. One topic we are likely to address is the extent to which this process is responsive to requesters’ needs.
In the second paragraph, members clarified that the fast track process was “necessary to facilitate successful implementation.” They summarized that the DSMO representative had responded to NCVHS’s request in extraordinary fashion, devoting substantial time and effort to meeting deadlines “and achieving industry consensus.” The group added that the DSMO’s success “bodes well for the ability of the HIPAA change management process to be responsive to future health industry needs.”
Discussion
The Subcommittee next discussed the pay and chase issues. Dr. Massey explained that the Medicaid state agencies often pay an entire claim, and then seek refund from a primary payer. The 837 is set up to pay from a plan to a provider; technical changes need to be made to it and 835 for them to be used in subrogation. However the Office of General Counsel determined subrogation was not the same as coordination of benefits and therefore not designated as a HIPAA transaction or a required standard. An NPRM could be issued in the future, if appropriate changes were made to the X12 set of transactions. Dr. Zubeldia noted subrogation could still be done using their version of the 837.
Dr. Gerber asked about several requests. He noted the discussion about request 191 and questioned whether the birth weight of Siamese twins was addressed. Ms. Greenberg noted that was an external value code and an NUVC issue. Noting requests 247 and 248 refer to the mammography recertification number, he asked if that was the NQSA facility certification number. Dr. Zubeldia said providers had the number for years; it was used on the NSF claims. Dr. Gerber pointed out that there is also a facility recertification number in FUSA. Members noted the need to clarify the mammography certification number.
Dr. Cohn acknowledged receipt of several letters. One from the state of California supported a delay of two years after the final rule is published, and identified local codes as a major issue. A letter from AAHP reaffirmed their testimony asking for a 24-month extension to commence upon the effective date of the last administrative simplification regulation to be adopted. Another letter was signed by the American Academy of Facial, Plastic and Reconstructive Surgery, American Academy of Virology, the American Medical Association, AMGA, American Public Health Services Association, Medicaid directors, Association of American Medical Colleges, College of American Pathologists, Health Insurance Association of America, and a number of provider groups. It called for extending the implementation period to two years, after all initial Administrative Simplification Rules have been issued and national identifiers for providers and health plans were available. They also sought a 24-month extension on deadlines. Dr. Cohn suggested members reflect on these letters as they focused on the letters to the Secretary.
Mr. Blair added that the Department had been asked to look at S-836, and huge problems were found with it. While, at this point, the Department had not taken a position on the delay, it said the bill, as drafted, was impossible and unworkable: if there were no standards for transactions to comply with, providers couldn't be covered in any of these. Therefore, they won't comply with the Privacy Rule; S-836 would “gut” the Privacy Rule. On the compliance side of HIPAA, Mr. Blair said S-836 would do two things. The sequence of rules coming out over 10-20-year period that HIPAA foresees would be cut off. (You’d have to have all the rules before anyone could comply with any of them.) And no one would have to comply with any rule released after that date--HIPAA’s compliance paragraph would no long pertain to anything happening beyond then. The House bill was virtually identical. The Congress had been given this information and the Department was providing technical assistance. Dr. Cohn suggested it might be useful, especially since they would be discussing whatever letter they agreed on, to go into that more fully in the update tomorrow with the full Committee. Asked if there was broad support for S-836, Dr. Braithwaite replied there was a lot of activity; he didn't know if it translated into broad support.
Agenda Item: Letter to the Secretary on HIPPA Implementation Recommendations
Members went through the working draft on the industry readiness issue (including written comments from Ms Fyffe, Dr. Zubeldia, and Mr. Blair) paragraph by paragraph. The first paragraph read: On May 31, 2001, the NCVHS Subcommittee on Standards and Security held hearings on the subject of industry readiness related to the administrative simplification of the implementation of the HIPAA regulations. Testimony was heard from a number of industry representatives and advisory group bodies, including AFEHCT, BCBSA, MGNA, NCPDP, X12, HL-7, AMA and state Medicaid agencies. From these testimonies as well as less formal industry roundtable discussions, the committee concluded the following:
The last sentence was amended to read, “From these testimonies as well as written statements and letters, the Committee concluded the following:”
1. There was overall agreement that HIPAA standards are necessary and viable. In all the testimony and comments heard by the committee, there was strong support for the administrative simplification provision for HIPAA, and for the efforts of HHS to promulgate the implementing regulations. In all instances, no negative feedback was perceived. The only concerns voiced were the speed and timeliness of the regulations.
Members noted concern was also expressed about the time needed for implementation. Dr. Cohn asked Dr. Braithwaite for help in drafting the final version.
2. There was general agreement that all the final rules, including security, claims attachments and national provider and payer identifiers, should be published as soon as possible. The reasons for this position were different for each entity, and included:
The final Security Rule is necessary to properly implement the final Privacy Rule.
The final Provider Identifier Rule is necessary to allow payers to design replacement claims processing systems that are not dependent on the intelligence currently incorporated into payer assigned provider identifiers.
The final Attachment Rule is needed to provide a significant return on investment for those entities that are already processing most of the other transactions electronically.
Members discussed adding other items to the bullets and concluded these three were the final rules testifiers singled out as rationale for asking for a delay. Dr. Zubeldia suggested revising the second bullet to read: “The final Provider Identifier Rule is necessary to allow payers to design changes to the placement of claims processing systems so they are not dependent.” Noting Secretary Thompson’s emphasis on uniformity, Dr. Fitzmaurice pointed out each health plan had a different provider number with different intelligence. The sentence was further amended: “…multiple payer assigned identifier numbers ….” The third bullet was changed to: “The final Health Claims Attachment Rule is needed to increase the number of claims that can be processed electronically and to reduce subsequent paperwork.”
Recommendation 1. To achieve the desired rapid publication of final rules, the NCVHS recommends that the Secretary play a leadership role in providing for orderly transition to publication. This role could include:
Providing early guidance. The Secretary could provide early guidance to the industry through letters or white papers revealing the direction taken by HHS. For example, a letter or white paper illustrating the size, format and rules for assignment of the national provider identifier could help current entities make progress on system changes before the final rules were issued.
Opposing open-ended delays. We recommend that the Secretary oppose open-ended delays of compliance as being detrimental to the industry, and the possibility of a successful implementation process. It is imperative that we not undermine the current efforts and continue to promote the urgency of working on the implementation standards.
The NCVHS observed that a fixed delay up to one year would not result in significant stoppage, and would allow the industry to continue on an orderly implementation schedule. Any delay greater than one year would incur significant stoppage and disruption. Since most entities in the health care system must comply with the standards to provide the benefits for all, this is a critical point. The Secretary could support legislative efforts in these directions. If a delay is proposed greater than one year, we recommend that it be accompanied by a schedule of interim deliverables/requirements so that the industry continues to move forward towards an orderly and successful implementation.
Dr. Zubeldia suggested an interim deliverable could be holding people to the schedule for claims and remittance advice, with a one-year delay for other transactions. The standards could be implemented on a sequential basis. Dr. Braithwaite remarked that all the standards could be implemented and the requirement delayed for the process, or people could be required to be ready on a date and given more time to put testing and agreements in place. Ms. Fyffe observed that “schedule of interim deliverables/requirements” was too vague for the Federal Register. They had to be explicit.
Mr. Blair suggested following that paragraph with Dr. Zubeldia’s example. Mr. Blair pointed out that with that “interim” might not be appropriate. Ms. Greenberg concurred that most everyone agreed on a schedule of phased requirements. Members noted Dr. Zubeldia’s suggestion would retain current compliance dates for the privacy regulations, health claims and remittance transactions and affect everybody that implements claims--a majority. Mr. Blair suggested they might offer eligibility and enrollment transactions six months later.
Dr. Fitzmaurice recalled hearing two things: some people wanted all the rules on the same date and then two years; others wanted no delay at all. No one had opted to implement all at once. What testifiers did want all at once were the rules. Dr. Braithwaite asked if there was a way to realize the recommendation heard and propose interim deliverables without phased implementation. Mr. Blair noted their vulnerability: interim deliverables implied a later date and interim basis. He suggested they could effectively accomplish the same thing with a schedule of phased implementation.
Ms. Trudel questioned if putting interim implementation requirements, with their one-size-fits-all approach, in the regulation could be enforced and efficient. Dr. Zubeldia reported it had been clear at the San Francisco meeting that there was no consensus on sequence, beyond claims and remittance advice come first. WIDI had made their recommendation, but there wasn't consensus. A participant noted another issue to consider was whether undue regulatory burden was being placing on providers. Dr. Zubeldia said the discussion was about lessening regulatory burden. Dr. Gerber reiterated the need for a way to show progress was made, that people took the right steps and were setting up the infrastructure needed. Dr. Cohn raised the question of whether to shed interim or phased. Ms. Greenberg replied “orderly” and “successful” conveyed a schedule. Dr. Massey suggested the term “intermediate requirements.” Dr. Fitzmaurice suggested each intermediate step had a compliance date. Mr. Blair supported Ms. Greenberg’s suggestion of an orderly schedule of requirements. Dr. Cohn agreed, but pointed out the need to indicate something must happen along the way. Mr. Blair said the examples would convey that the claims and remittance went forth unchanged, while others waited. Dr. Cohn recapped that the examples were (1) doing the claims and remittance advice first, and delaying the other transactions, (2) having all the transactions ready by a specified date, but allowing additional time for implementation and testing with trading partners, and (3) implementing all the transactions on a specific date, but allowing the process to be delayed for code sets and identifiers.
Rapid issuing of identifiers. Delays in issuing identifiers for some subsets of entities in the health care system will cause increased expenses to those who must run parallel systems on the old or new systems simultaneously. The NCVHS recommends that once the system for assigning provider identifiers is ready, identifiers should be issued very rapidly to all providers, so that transition time is limited.
Dr. Braithwaite pointed out this opposed what was proposed. There was money to issue Medicare identifiers, but not to issue identifiers to other providers. This said abandon that and do it all at once—which was contrary to what they proposed for identifiers. Observing that the payer has to maintain both systems as long as providers continue to use old numbers, Dr. Cohn recommended deleting “to some subsets of entities in the health care system.” Members discussed recommending, later on, that the Secretary identify additional funding for the providers to get identifiers. Dr. Cohn remarked that the next bullet, logically followed delays.
Allowing flexibility in enforcement. Realizing that the administrative sub-title of HIPAA requires compliance within 24 months, the NCVHS recommends that the Secretary explore the flexibility available to him for enforcement under Section 1176 of HIPAA, and publish his intent to utilize this flexibility in enforcement to ameliorate industry concerns. The Secretary could do this by monitoring the implementation situation in the industry, in granting criteria based leniency in enforcement as deemed necessary.
Dr. Zubeldia noted concern expressed by the AMA and the Medicaids that, even though the Secretary might be lenient in enforcement, the states might require providers be compliant. Dr. Fitzmaurice suggested that advising the Secretary they heard he should be flexible on enforcement and that flexibility was available might be enough to give him a “hook.” Dr. Braithwaite emphasized advising the Secretary to publish his intent; he pointed out that could be as simple as putting out the Enforcement Rule.
Recommendation 2. The Committee recognizes that to achieve rapid publication of the final rule, it is essential that the Secretary apply the necessary resources to reaching this goal. This would include the ability to require means for promulgating the rules and implementing the identifiers.
Members discussed that there were two ideas under recommendation 2: rapid publication of the final rules and implementing the identifiers. The concern wasn’t the delay in issuing identifiers, but the prolonged period during which identifiers were issued. A longer transition increases expenses for those who must run parallel systems, which was why Mr. Reynolds testified he wanted everybody to have the identifier within three months. Mr. Blair pointed out that they might have lost balance. The American Medical Informatics Association, HMSIS, or CHEM, which all said don't have any delays, were not among the testifiers. They were writing their letter only in response to people asking for delays. Dr. Zubeldia observed that while providers would initially receive their own personal identifier, entities will keep asking for identifiers for a long time. He didn't know that it was even possible to achieve that three-month issuance time frame Mr. Reynolds talked about.
The following was added as a separate paragraph in 2: A prolonged process for issuing identifiers will cause increased expenses to those who must run parallel systems,
Recommendation 3. The committee believes that HHS should expedite the change process, so that the changes in standards that are voted on by the industry and recommended are promulgated in final rules as soon as possible. To assure this process, the NCVHS recommends that the Secretary provide the necessary leadership and resources to have these changes advanced as soon as industry consensus is achieved.
Recommendation 4. Since the data requirements of the HIPAA standards for electronic claims are not identical to their use in current paper claims forms, the NCVHS recommends that the Secretary ask the NUCC and AUDC to explore ways such as issuing the implementation guide for each paper form to make the data used on paper claim forms compatible with the HIPAA standards.
Dr. Zubeldia noted this could be misinterpreted as recommending that all the data elements from the A-37 be included in the paper form. Dr. Massey said the biggest concern heard was getting a uniform set of instructions for the paper form, because the data differed so much. It was noted that unlike NUCC, NUVC had an implementation guide, but it was inconsistent with the HIPAA standards. The last sentence was amended to read “consistent with the HIPPA standards.”
The last point in the letter (Recommendation 5. It is also recommended that the Secretary work with industry accreditation organizations to delay using HIPAA compliance as part of the accreditation process until the Secretary determines that the organizations have sufficient time to comply) was deleted.
Mr. Blair noted another missing idea. The letter asked the Secretary to start focusing on these things and consider whether or not to issue relief, but never said when. They were in a dynamic situation, and had seen dramatic changes with the providers’ stepping up their readiness. Getting out the security regulations and provider I.D. in three-to-five months might change industry perceptions and readiness much more. He said he didn’t know whether to recommend that the Secretary try to make those changes now or (if the security “regs” and provider I.D. would be out in a few months) test the water then to see what delays were appropriate. Dr. Fitzmaurice called that “optimistic.” He said his esteem for the Department would increase beyond what it already was if all that happened in five months. Mr. Blair responded that, if it wasn’t realistic to expect them before the end of the year, maybe the letter’s recommendations could be implemented by September or October. Dr. Cohn suggested the question was whether to use “immediate” or “urgent”: a leadership role needed to be taken now. Mr. Blair said he was inclined, hearing Dr. Fitzmaurice’s view, to leave it as it was. Dr. Cohn remarked he was concerned that the people involved in this, overworked and with competing demands, needed help. The Secretary needed to devote attention to this.
Dr. Fitzmaurice remarked nobody wanted a delay; people wanted the system in place and running. But they heard a lot of reasons why some people thought a delay was in order. He said he heard the Subcommittee saying it recognized some delay might be inevitable. At most, one year is what they seemed to recognize. Dr. Cohn said in drafting this, he tried to stay relatively neutral regarding a delay, focusing on the characteristics, needs, and not undermining momentum. If this was interpreted as asking for a delay, he said he had gone too far,
Ms. Fyffe suggested, in line with Ms Greenberg’s and Mr. Blair’s view, that as a federal advisory committee they were obligated to report what they heard during open public testimony. They had to report the themes of the testimony--and take a stand. If they weren’t comfortable speaking for the whole Committee, then they had to get them to speak on this tomorrow and document those thoughts in a letter to the Secretary.
Mr. Blair suggested stating that, while the Committee does not recommend a delay, it recognizes there is considerable pressure from some sectors in the industry. If the Secretary chooses to respond to those pressures, here are their recommendations. Dr. Braithwaite noted the Secretary couldn't arbitrarily change the compliance dates without an act of Congress. However, he could take a position the NCVHS recommended and respond to Congressional approval.
Noting they had from heard both ends of the spectrum, members amended the second paragraph of the second item in recommendation one: “NCVHS heard from some testifiers that a fixed delay up to one year….”
Ms. Trudel pointed out there was no clear statement from the Subcommittee about the more important issue on the table--the delay. Dr. Fitzmaurice suggested they advise the Secretary to: spend resources, take leadership, and put things out as fast as possible so that there are no delays. Ms. Trudel added they weren’t necessarily asking him to do anything; but simply informing his decision-making process. Mr. Blair cautioned whatever they recommended might be interpreted by the Congress as a recommendation for a delay. Ms. Greenberg noted that’s what the letters and the proposed bill were all about; her impression was that the subcommittee didn't support that. Dr. Zubeldia said they needed to clarify that they considered such proposals an open-ended delay.
Mr. Blair reflected that the reason they had such difficulty being explicit about their recommendation was that they didn't have enough information. Probably no one had enough information, at this point, to explicitly say, delay this piece for so long. Maybe they should recommend no delay until determining which transactions wouldn’t be ready by which portions of the industry.
Members observed that that the transaction implementation guides had been out (and draft regulations written) since 1998. The process was already delayed and the Secretary needed to know he was continuing that delay: dates couldn’t be set for when new transactions would come out. If the Secretary agreed to a delay, he was agreeing to further delay.
Ms. Greenberg observed that, usually, a full report from the Committee would report on what the Committee heard and findings and recommendations. Noting Mr. Blair “lobbed a bombshell on the table that he was trying to stay far away from,” Dr. Cohn pictured this letter as more a synthesis of recommendations and views and what was heard, filtered by their experience-- because this was so political, it wasn’t just a discussion of facts, but more what they believed to be successful strategies.
Mr. Blair suggested a paragraph stating that before considering any delays, the following assessments of industry needs must be taken: transactions the industry will not be ready for, code sets which they will not be ready for, how much time will be needed, and which segments of the industry will be effected. Dr. Braithwaite remarked that this, itself, was a delay.
Dr. Cohn noted one reason they were meeting was that everybody was painfully aware that they were not going to reach consensus. The best he had thought they might do was get to their positions. He reiterated that the Secretary is not the one making this final decision: they could send a letter advising the Congress. The Secretary could support or not support laws, but they couldn't advise him about considering a delay.
Dr. Cohn remarked that he had thought they were all definitely against open-ended delay (which needed to be further defined for the Secretary and others), but that a one-year delay would probably not hurt things too much. But if there was a delay, it absolutely had to have interim deliverables. He was trying carefully to skirt the issue of a delay--But how they approached this was the will of the Subcommittee.
Mr. Blair said Ms. Fyffe’s suggestion to strike the third item within the first recommendation could reconcile things. They had agreed on all parts of the letter. Drs. Zubeldia and Cohn had modified it to say “any delay.” If that paragraph were deleted, they wouldn't go down the path of saying, “if there is a delay.” Dr. Zubeldia said the Congress was considering a delay and they had to address that possibility; he would rather recommend a solution than be silent. Ms. Greenberg noted in striking that, they would lose the concept of intermediate requirements or interim deliverables. Dr. Zubeldia, Mr. Blair and Ms. Greenberg all called for a strong definitive statement saying that the Subcommittee does not support a delay at this time. Ms. Fyffe reiterated that they needed to help the Secretary understand that there has been tremendous delay already since this law was signed in 1996.
The group noted they had heard from a number of industry sources, including those that asked for a delay and others opposed. Dr. Zubeldia observed that in a meeting last week to consider the impact of delaying the implementation schedule by one year, they couldn't find any deliverables or progress to be gained. Dr. Cohn said that was the reason for an amended implementation; they heard the need to move forward.
Ms. Greenberg pointed out that the Secretary faced a bill recommending, “Wait until everything is out there.” If they were too subtle, either with the Secretary or the industry, it would sound like the committee recommends a delay. While a delay, used constructively, could be appropriate, members agreed that they hadn't heard a proposal, neither by the Congress nor any testifier that justified their support. Ms. Trudel added that they especially didn't like an open-ended one. What would the proposal for a delay have to include to be beneficial and productive?
The third item in recommendation 1 was amended to say the committee doesn't support a delay and “particularly opposes open-ended delays such as that found in 836.” Dr. Cohn acknowledged the lack of a quorum, but observed they were only drafting a letter. Mr. Blair said he was gratified with the unanimity expressed; at least they didn't have a split committee. Noting how controversial the issue is and how difficult it is to get even majority consensus in the committee, Dr. Cohn said he was trying to steer away from “the bull in the china shop,” but they had to handle it one way or another. Anticipating interesting discussions with the Committee and expressing some concern about ending up with a letter to give to the Secretary, the Subcommittee moved on, reflecting they were not that far from accommodating the suggestions.
Members discussed a draft of a letter to NUCC and NUVC. Instead, they decided to send a copy of the letter to the Secretary on implementation recommendations, noting point four about issuing the implementation guide for each paper form to make the data used on paper claim forms compatible with the HIPAA standards, a topic actively under discussion in both groups. Dr. Cohn said they would inform the full Committee that they would send the approved letter and note.
Ms. Trudel read the transmittal letter to the Secretary on HIPPA implementation. As part of its responsibility under HIPAA, the NCVHS provides advice to you regarding standard electronic transactions and code sets adopted under HIPAA. NCVHS has recently reviewed its first recommended set of changes to these standards as recommended by the DSMOs. The DSMOs are a set of organizations that have been designated by the Department to modify the standards based on industry input.
The first set of changes was produced by the DSMO's as a fast track process the NCVHS requested to expedite changes that are necessary to facilitate successful implementation. The process required the DSMO's to do their review and analysis work in compressed time frame, so that the changes could be made to the standards during the first year after adoption, and in time to assist with initial industry implementation. The DSMO representatives responded to the NCVHS as requested in extraordinary fashion, devoting substantial time and effort to meeting our deadlines and achieving industry consensus. They are to be highly commended. Their success bodes well for the ability of the changed management process to be responsive to future health industry needs.
The NCVHS has reviewed the DSMO recommendations for changes to the standards. We advise you to accept all of these changes, subject to technical corrections, and begin the regulatory process to adopt these changes as part of the standards. In addition, we urge you to expedite the process so that health plans, providers and clearinghouses can draw up these necessary changes as soon as possible. We recommend that the final rule implementing these changes be published no later than January 31, 2002.
Members amended the second sentence in the third paragraph to read, “We recommend that you accept all the technical changes, subject to technical corrections….”
It is clear that the HIPAA code sets do not cover all procedures and diagnoses. This will always be a problem due to the evolving nature of health care. This seems to be particularly true in certain specialties or in emerging areas of care, including mental health, disability, long term care vision and hearing and wellness services.
We endorse the DSMOs' position that such code set gaps are most appropriately filled by modifying existing HIPAA code sets. We are planning to address broader issues related to code sets and terminologies beginning sometime in the late fall or winter. One topic we are likely to address will be gaps in the HIPAA code sets and the extent to which the maintainers are working with industry to fill them.
Members agreed to delete the sentence about mental health, disability and long term care. They amended that paragraph’s first sentence: “It is clear that the current HIPAA code sets …”. Members noted the letter needed to clarify the endorsement of the DSMO’s position to develop strategies for addressing the gaps; before new code sets could be considered, the first strategy was for requesters to work with the maintainers of the currently designated code sets.
Thanking everyone, Dr. Cohn adjourned the meeting at 5:00 p.m.
I hereby certify that, to the best of my knowledge, the foregoing summary of minutes is accurate and complete.
/s/ Simon P. Cohn 6/03/2003
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Chair Date