June 17, 1998
Health Care Financing Administration
Department of Health and Human
Services
Attention: HCFA-0149-P
P.O. Box 26585
Baltimore,
MD 21207-0519
To Whom It May Concern:
The National Committee on Vital and Health Statistics (NCVHS) is pleased to submit the following comments on the Notice of Proposed Rule Making (NPRM) labeled HCFA-0149-P.
Upon reading the Notices of Proposed Rule Making published on May 7, we are pleased to have contributed to this effort and find that the Secretary has indeed relied on the advice of the National Committee on Vital and Health Statistics. Therefore, the following comments deal almost exclusively with selected issues on which comments were requested specifically in the NPRM.
On the issue of the impact of electronic standards on the long-term care industry:
As part of its monitoring of standards adoption for its annual report to Congress, the NCVHS will be interested in hearing from representatives of the long-term care segment of the health care industry. However, we believe that the proposed standards offer the opportunity for all segments of the health care industry to adopt automation and to benefit from such adoption. Long-term care providers may elect not to use electronic transactions, just as other providers may do. Yet, when long-term care providers elect to use electronic transactions, the standard provides them with a single method that can be exchanged with all payers. This offers much greater incentives to adopt electronic transactions than currently exist. The NCVHS believes that it would be an unfortunate precedent to exempt segments of the health care industry from these rules.
On the issue of scheduling early implementation of the standards to avoid disruptions and ease the transition:
The NCVHS concurs with the recommendations that came from the Workgroup on Electronic Data Interchange (WEDI) at their Healthcare Leadership Summit in August 1997. Under that recommendation, willing trading partners could implement any or all of the standards by mutual agreement at any time during the 2-year implementation phase (3-year implementation phase for small health plans). However, health care providers should not be required by health plans to use any of the standards during the first year after adoption of the standards, and a health plan should give its health care providers at least 6 months notice before requiring them to use a given standard. These recommendations offer a realistic and functional approach to management of the 2-year implementation schedule and, most importantly, this approach would remove many of the disincentives to early implementation. The NCVHS recommends that this implementation schedule be incorporated into the Final Rules, if there is legal authority to do so, to reduce the uncertainty and ease the transition period for all segments of the health care industry. If this goes beyond the authority accorded by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), we urge the Department of Health and Human Services (HHS) to identify other mechanisms to accomplish this objective.
On the issue of adoption of universal product numbers (UPNs) as a national coding system:
Just as the adoption of national drug codes (NDC) to replace Health Care Financing Administration Procedure Coding System (HCPCS) "J" codes was the right thing to do at this time, the NCVHS believes that movement toward adoption of UPNs is essential and compatible with the administrative simplification philosophy of adopting standards whose maintenance is the responsibility of the private sector. To this end, we urge HHS to begin planning a smooth transition to UPNs nationwide. As a first step, HHS should monitor the adoption of UPNs by the Department of Defense and California Medicaid to learn about the benefits and pitfalls of using UPN codes for coding and for payment in real-world applications. Further, we urge HHS to work with these and other relevant organizations to overcome the limitations cited for UPNs currently. As part of its continuing interest in coding and classification standards, the NCVHS will continue to monitor activity in this area to assist in the transition to one national system of UPNs that can be adopted for health care.
On the issue of eliminating local codes from HCPCS and establishing a process for supplying new codes when necessary:
Today, local codes (HCPCS Level 3) are adopted by health plans to fill the gaps where no national code exists for particular services. However, there is no process currently for extending these codes to national coverage. The NCVHS believes that elimination of local codes, when coupled with an expedited process for establishing new codes, is essential to achieving the goal of administrative simplification. To remove these impediments to simplification, we recommend that HHS provide the resources necessary to establish and support the infrastructure to replace local codes with permanent national codes that will meet the business needs of health plans and providers. Similarly, we support the adoption of national coding guidelines for diagnosis and procedure coding and a process to maintain them.
In addition, we reiterate our willingness to work with HHS and other organizations toward the development of a unified framework for coding procedures. As noted in our June 1997 recommendations to the Secretary, we recommend that HHS identify and implement an approach for procedure coding that addresses deficiencies in the current systems, including issues of specificity and aggregation, unnecessary redundancy, and incomplete coverage of health care providers and settings. The committee will continue its leadership and participation in this endeavor.
On the issue of using the X12 834 enrollment transaction for collecting demographics:
The NCVHS recognizes that demographic information is very important to health care provision and research, and we believe that the 834 is the appropriate vehicle for collecting such information. The 834 transaction already includes the necessary data elements and offers a method for collecting demographics that, while imperfect, is likely to be superior to third-party observation, which is the method commonly used to collect demographic detail for health care claims and encounter records. To ensure that demographics are available for use with claims and encounters for health care and research, we urge HHS to take a proactive stance to encourage employers, sponsors, private health plans, State Medicaid agencies, and the Health Care Financing Administration to adopt the 834 enrollment transaction and to make those data available, under stringent safeguards, for legitimate purposes.
On the delay in adoption of the first report of injury transaction:
When the NCVHS recommended adoption of the ASC X12N 148 for the first report of injury transaction, we expected that the 148 would be completed and ready for adoption with the other eight transaction sets in this NPRM. Unfortunately, that has not happened. Therefore, we concur now with the HHS analysis that the functions covered by the first report of injury transaction need to be more limited and consensus on the standard needs to be reached. To this end, we urge X12N and the International Association of Industrial Accident Boards and Commissions (IAIABC) to work together to produce a compatible transaction architecture and data content that can be adopted by HHS within the next year.
On the issue of mechanisms for assessment of compliance with standards:
The NCVHS believes that HHS must encourage the private sector to take the lead in these areas. The 2-year implementation period may be the time when the greatest need and the greatest incentives exist for industry cooperation in this area. During this time, we would expect that a number of organizations that represent standards developers, health plans, health care clearinghouses, health care providers, and/or vendors would have an interest in ensuring that independent validation, testing, and certification take place. Later, there may arise sufficient incentives for the market to supply these functions. Regardless, it does not seem practical or necessary for the Government to undertake these activities.
On the issue of designing a process to handle requests for new or revised standards:
Under HIPAA, the Secretary of HHS is the final arbiter of which standards are adopted and how they are changed. However, we urge HHS to consider having the process for evaluating proposals for new standards (including requests for waivers and testing) rest with a private sector organization with public sector involvement. Such an organization could operate under guidelines set by HHS in the Final Rules. These guidelines should incorporate those principles proposed in the NPRM, including the ANSI accreditation principles for processes which are followed by accredited standards development organizations and are proposed below for the content committees.
On the issue of establishing data content and maintenance committees and their processes:
The NCVHS believes that HHS should specify and establish guidelines in the Final Rules for the operation of data maintenance and content committees. We believe that such committees, if not ANSI-accredited, should operate in accordance with four principles: (1) Public meetings should be held, at reasonable cost and at reasonable intervals. (2) Meetings should be broadly announced to reach interested and affected parties. (3) Changes in products should be broadly announced to reach interested and affected parties. (4) There should be evidence of responsiveness to public input. Because there are several specific issues to be resolved concerning the operation of data maintenance committees, the NCVHS intends to hold hearings to advise HHS on future rules that might be appropriate.
On the issue of what committees should be designated, the NCVHS recommends that there not be separate data maintenance committees for each X12 transaction. For administrative simplification to succeed, linkages and relationships among X12 transactions need to be acknowledged and, when changes to the content of one transaction are considered, the effect on all other transactions needs to be considered as well. This is not to say, for example, that the American Dental Association's responsibility for the dental claim should be transported to another body. Rather, it is to recognize that a coordinated approach to data maintenance is necessary and the number of bodies that can effectively manage such coordination should be limited. Whether this coordinating function should remain the responsibility of X12 or whether a superstructure for data maintenance committees is necessary should be evaluated with an eye toward achieving a careful balance between costs and benefits.
On the issue of ongoing Federal oversight/monitoring of maintenance processes and procedures:
As long as authority to adopt and modify standards rests with the Secretary of HHS, a certain amount of Federal oversight and monitoring must take place. However, the level of HHS involvement can be minimized by the requirements suggested above.
Sincerely,
Don E. Detmer, M.D.
Chair