The HIT Transition Weblog

New HIPAA Standards Clear Regulatory Hurdle, Approach Flaming Commentary Hoops

Tired of the ambiguities and outdated constraints of the electronic claim, remittance advice, eligibility and other X12 transactions? Help is on the way.  Or at least it's coming into view.

The enabling regulation to adopt a new version of those standards has cleared the Department of Health and Human Services and has been passed on to Office of Management and Budget for final review. OMB has 30 days [OOPS! Meant to verify this before posting. In truth the rule of thumb is 90 days for the review; insiders say it is on a fast track, though. -Ed.] to approve it (with or without revisions negotiated with HHS) or reject it.

I was fortunate to have the opportunity to participate in some of the X12 workgroups that built the new standards, and am certain that the new standards will improve efficiency and reduce the number of customizations and workarounds.   We won't be able to say goodbye to those nasty Companion Guides, but at least they will be thinner.

Besides reducing ambiguity in hundreds of passages -- saying when NOT to send data as well as when to send it, for example -- the updates incorporate a number of issues currently vexing implementers:

• Unambiguous instructions for consistent implementation of National Provider Identifier submissions across all transactions and all payers.
• Intrinsic support for the Present on Admission data, rather than the K3 stopgap introduced last year.
• Support for the ICD-10 codeset, not available in the current 4010A1 standards.
• Better, clearer remittance advice instructions and standards, including mandatory utilization of the Remark Codes segment.

The standards were developed over a period of months and published back in 2004 and 2005. First the draft guides were released for public comment, then the workgroups responded to each of comments and finalized the implementation guides (now referred to as "Technical Report 3's" or TR3's) and submitted them for approval via X12's consensus process.

It has taken three years for HHS to put together the regulatory language to adopt them.

And once that draft regulation is released will come another comment period.

Um, what was that?

X12 is anxious about this. Tagging a regulatory comment period on to the standards development comment period brings a lot of new participants out of the woodwork. While techically this may improve the end result, it also stands to send the standards folks back to their own review/comment/edit process, further delaying implementation.

Last time this happened, it was under the deadline for adoption of the original HIPAA standards -- the finished 4010 guides got hurriedly updated with the A1 Addendas, and the industry has had to work out of two sets of books ever since. (I recommend purchasing the Combined Guides for those who have difficulty reading out of two volumes at once. They're not "official" but they will keep you from making a lot of errors or at least getting a lot of headaches. Go to www.wpc-edi.com and check out the HIPAA link.)

I haven't been able to participate in X12 for awhile, but I know they are all over this. I hope that some of their collaboration with the regulators produces both better standards and better adoption processes.  We soon shall see.

Is 5010 a Year?! Why HIT Standards Take So Long...

You thought I was just being clever last week when I quipped, "These umbrage-and-edit timelines rachet out to make the electronic claim standards developed three years ago available for widespread adoption sometime after the the turn of the decade, even with optimistic dependency scheduling."

Oh, no.  I had inside information.  And that information became public this week.  The North Carolina Healthcare Information and Communications Alliance and The Workgroup for Electronic Data Interchange have been working on a real live MS-Project-based timeline to show regulators and industry analysts just how much time is consumed in developing, adopting and implementing HIT standards.  The equation for the 5010 version of the electronic claim and other ASC X12 administrative transaction adds up to 2014 -- that's seven years from now to implement a standard I helped smarter people finalize almost three years ago. 

According to Holt Anderson, Executive Director of NCHICA,

“Our estimate is based on the key assumption that a proposed rule on 5010 will be published in June 2008, and if only minor revisions are made, a final rule will be published in 2010. It is projected that it will take three years to move to limited production of new standards and one year to move to full compliance, bringing us to 2014.”

Don't believe it?  Check out the details on the WEDI/NCHICA site devoted to the study.  And if you still don't believe it, download the MSP file and plug in your own assumptions. Heck, join in the conversation on their listserv!  The link says "membersonly" but it's supposed to be open to everybody.  If you have any difficulty subscribing, shoot me a note and I will inform the powers-that-be.

Link to All CMS NPI FAQs

Many moons ago, I wanted to share a query string that would bring up all CMS FAQs that include the term "NPI."  That was preferable to linking to specific items, because new items were being constantly being added.  I did the search query on the CMS site, which created a URL that was a mile long.  I systematically eliminated components of the string until I came up with something that produced the desired results, but was only a furlong or two in length.

I've given this out before, but I didn't have a direct, isolated link on my blog, so here it is.  You can click on the big ugly string, but that often gets broken in pieces when you copy/paste/send via email, so if that's an issue, you can link people to this blog post by copy/pasting the second string.  (I don't use tinyurl because I'm not sure what they are selling to do what they do for free.  I am selling mostly free information with a few fee-based webinars and mostly-free presentations and white papers thrown in).

Big Ugly String to CMS NPI FAQs
http://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_alp.php?&p_page=1&p_search_text=NPI&p_new_search=1&p_search_type=answers.search_nl&p_sort_by=&p_gridsort=4%3A2

Short Friendly String to this Blogpost
http://blog.hittransition.com/2007/08/link-to-all-cms.html

CMS Lists Common NPPES Mistakes

CMS-the-regulator has rescheduled release of NPI data for the end of July, but has warned providers to update their records by the 15th or risk dissemination of private and/or bad data.

Now CMS-the-payer is warning providers of specific problems in their NPPES record that might lead to Medicare crosswalk errors (read "unpaid claims").

Check it out at MLN Matters SE0725.  It's a pretty helpful document, and contains lots of good advice to those providers who don't bill Medicare, too.  Also contains useful stuff about how Medicare will map NPIs from 837 Claims to 835 Remittances.

Reasons Require Remarks: Changes within the Standard

The ASC X12 835 Health Care Claim Payment/Advice (often referred to as "Electronic Remittance Advice," or ERA) is supposed to enable providers to post payments and adjustments without manual review.  One important enabling technology is the complex relationship between codes that explain how to deal with each detail:

• The Claim Adjustment Group Code ("Group Code") is a short list of qualifiers to describe the type of adjustment.  These include PR (Patient Responsibility), CO (Contractual Obligation), CR (Corrections and Reversals) PI (Payer Initiated) and OA (Other Adjustment).  This list cannot be changed without a change in the implementation guide.  Since we're several years away from the first possible adoption of such a revision under HIPAA, the codes you see are the codes you get.
• The Claim Adjustment Reason Code (CARC) is a dynamic list, maintained by The Claim Adjustment Status Code Maintenance Committee.  The CARC is a mandatory data element in the 835 -- for each adjustment, you have to give a reason.
• The Remittance Advice Remark Code (RARC) is a more detailed list, primary used to expand upon the basic information provided by the pairing of a Group Code and a CARC.  This segment, however, is not required, and a lot of payers do not include it in their remits.  Like CARC, the RARC is an external code list, which allows for ongoing revisions, additions, and deletions.  RARC is maintained by CMS's Remittance Remark Advice Code Maintenance Committee.  These values go into an optional segment -- Medicare uses that segment as do some other health plans.

A recent modification of the CARC and RARC lists -- and the implicit relationship between them -- constitutes a change in the way the 835 works.  That change is beneficial to all parties, though it may not be appreciated by some.  Most significantly for providers, it will prevent many of the unexplained denials that currently frustrate their ability to automate 835 processing.

A Look at the CMS Data Use Agreement

Yesterday I published a story suggesting that executing a data use agreement (DUA) might be an alternative to waiting for CMS to publish and finalize its long-awaited NPI Data Dissemination Policy. I have since received confirmation that this is, in fact, the case.

But sources have also expressed concern that CMS does not relish the thought of being inundated with such requests, and that, as owner of the data, CMS would be in the position to accept or reject them as they see fit.  They may not be in a mood to approve hundreds or thousands of such requests while that formal disclosure policy, with its CYA benefits, is 'finally about to be released.' 

Perhaps a look at the actual form, CMS R-0235, with respect to the NPI, would be in order.

NPI Data Dissemination vs. Data Use Agreement

Just got a tip from a colleague that CMS may be allowing access to NPPES data (the NPI database run by enumerator Fox Systems) prior to the release and approval of the much-delayed Data Dissemination Notice. 

Big News Day
For people trying to solve the National Provider Identifier problem, this would be bigger news than the simultaneous announcement by CMS parent HHS that Robert Kolodner, chief health informatics officer at the Veterans Health Administration, will take on David Brailer's job, at least on an interim basis.  (It had been suggested that it would be hard to get someone from private industry to take on the review process, much less the role, for an official appointment, given the short period of time left in the administration's tenure  This fits with the indication that Kolodner would serve as acting national coordinator for health information technology.)

Back to Data Dissemination
The hue and cry for access to NPI data has been growing steadily since we and others first started asking about it after the release of the final rule.  "Real soon now," was the reply, as CMS wrestled with federal regulations regarding personal identifiers and external pressures to keep a tight lid on the as-yet-undeployed physician identifiers.

Without access to this data (and after many delays in the anticipated release of the policy), healthcare organizations have been relying on haphazard and error-prone point-to-point exchanges of NPI and related data.  Not just payers, but provider organizations.  Hospitals, reference labs, physicians who require referrals and preauths -- anyone who must list other providers on their claims -- were slowly beginning to realize how difficult it would be to send NPIs without the ability to look up NPIs. 

Worse, the early adopters were discovering a nasty uptick in demand for extra paperwork -- no standard procedure exists, so each payer was devising their own way of obtaining and verifying NPIs. Medicare led the way by requiring a hardcopy of the NPPES notification from the enumerated provider, which, flimsy as it was, remained the only method of NPI validation sourced from NPPES available to an external party.

Just Lost a Gig

I just learned that a promising prospective client decided not to have me jet in and solve all their NPI problems.   The project manager had been optimistic and enthusiastic, but her management opted to go with a local firm that had the backing of an excellent national HIT consultancy.  (Nice to lose out to the best, right?)

My loss could be your gain...I now have a four-week hole in my near term schedule.  Anybody looking for an NPI guy?  Drop me a line.