webinar

1. webinar Update on Health Care Service Data Reporting Guide Presented by Bob Davis with a special thank you to Ginger Cox April 14, 2010

2. Standards PrimerPage 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

3. 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 impacton the ASC X12 standards.

4. Impact of PHDSC on ASC X12Important 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.

5. 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

6. 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.

7. 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 • 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

8. 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.

9. 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 Data Elements supported bythe HCSDRG

10. 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

11. Change Specifics

12. 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.

13. 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.

14. 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 Numberfor institutional and professional services to support this need)

15. 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.

16. HCSDRG Changes Reporting Guide Changes in 5010 (October 2003) • 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.

17. Present On Admission Coding Tutorial • The recommended values for reporting POA are: • Y Yes • N No • U No Information in the record • W 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, Medicaredecided 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*.

18. Language – Some Details Synonyms • 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.

19. 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).

20. 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.

21. 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)?

22. 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-care-data.asp

23. Those Pesky Acronyms Defined Acronyms • 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

24. 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 ANSI-accredited 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.

25. 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

26. Questions

27. Parting Thoughts To Move Us Forward

28. Do not get yourself in trouble!

29. Aim High!

30. Stay focused on your job

31. Exercise to maintain good health

32. Practice Team Work

33. Rely on your trusted partner to watch your back

34. Save for raining day

35. Rest and Relax!!!

36. Always smile when your boss is around

37. And remember … nothing is impossible!

38. Contact Information Consortium website: http://www.phdsc.org Bob Davis rdavis@nahdo.org 518-456-1735