Action Resources:
Transactions & Code Sets
and Identifiers

The Final Transactions and Code Sets (TCS) Rule was published in the Federal Register on August 17, 2000. The compliance date is October 16, 2002 (October 16, 2003 for small health plans and for those who submitted a compliance extension plan per the Administrative Simplification Compliance Act (ASCA), with a transactions testing deadline of April 16, 2003).

Corrections to the Final Rule were published on November 24, 2000.

Modifications to the Transactions and Code Sets Standards were published on February 20, 2003, combining two proposed rules and adopting modifications recommended by the Designated Standards Maintenance Organizations (DSMOs), adopting a revised National Council for Prescription Drug Programs (NCPDP) standard for batched retail pharmacy transactions and a revised standard for pharmacy remittance advice and prior authorization, and retracting the National Drug Code (NDC) as the standard for drugs in all transactions except retail pharmacies. The compliance date for the Transaction Modifications Final Rule is October 16, 2003.

HHS' Centers for Medicare & Medicaid Services (CMS) issued a guidance document on compliance with the October 16 TCS deadline July 24, 2003.

The Final National Provider Identifier (NPI) Standard was published in the Federal Register on January 23, 2004. The compliance date is May 23, 2007 for most covered entities (May 23, 2008 for small health plans).

The Final Employer Identifier Standard was published in the Federal Register on May 31, 2002. The compliance date is July 30, 2004 for most covered entities (August 1, 2005 for small health plans).

A Standard National Health Plan (Payer) Identifier has not yet been proposed.

Reports
Articles

Reports

On Track with TCS Testing -- Critical Steps to the Compliance Deadline by John Yates & Randa Upham, Principals, Phoenix Health Systems

The Provider-Clearinghouse Relationship -- 10 Questions for Successful Transactions Compliance by Ward Keever, SeeBeyond

HIPAA TRANSACTIONS: Making it to the Finish Line
by Kepa Zubeldia, M.D.
Those in healthcare administration can benefit from objective, third-party transaction testing and certification. Initially, it can enable organizations to get past the fear of public failure, and to survive the HIPAA transition and realize the administrative savings that transactions standardization will generate.

CMS Presentations:

The Who, What, When, Why & How of NPI: Information for Health Care Providers educational flyer from CMS is designed to provide basic NPI information to providers who are enrolling in the Medicare program. As of May 1, 2006, healthcare providers are required to have a NPI prior to enrolling, or making an enrollment change, in the Medicare program.

CMS' Provider HIPAA Readiness Checklist is designed to help healthcare providers start thinking about what they need to do to prepare for meeting the electronic transactions and code sets requirements. (Available in English and Spanish.)

BlueCross/BlueShield's "HIPAA Transactions and Code Sets Toolkit" (PDF)

WEDI SNIP Compliance White Papers & Presentations:

CMS' HIPAA Information Series of 10 PDF documents on complying with HIPAA's Electronic Transactions and Code Sets Standards Requirements:

HIPAA 101 for Health Care Providers' Offices
Educate yourself and your staff on the basics of HIPAA law.
Are You a Covered Entity?
Determine whether you are a covered entity under HIPAA.
Key HIPAA Dates and Tips for Getting Ready
Be aware of the HIPAA deadlines right around the corner and take steps to prepare for compliance.
What Electronic Trans. & Code Sets are Standardized Under HIPAA?
Review your business operations and the HIPAA Electronic Transactions & Code Sets.
Is Your Software Vendor or Billing Service Ready for HIPAA?
Communicate with your vendors, billing services and clearinghouses. Know what questions you should be asking them.
What to Expect from your Health Plans
Insure you have the necessary two-way communication with each of your health plans. This is essential for compliance.
What you Need to Know about Testing
Test your office operations and insure that those who electronically process claims on your behalf have a testing plan in place.
Trading Partner Agreements
Investigate and understand your Trading Partner Agreements with your health plans.
Final Steps for Compliance with Electronic Transactions & Code Sets
Take those final steps towards compliance and do not hesitate to get the help you need.
Enforcement
Learn about CMS’ enforcement approach.

The HIPAA final standards for electronic health care transactions, and for code sets, adopts the National Council for Prescription Drug Programs (NCPDP) Telecommunication Standard Format, Version 5.1, and the NCPDP Batch Standard, Version 1 Release 0, for pharmacy claims. Health plans, healthcare clearinghouses and healthcare providers who utilize electronic transactions are required to use these standards beginning October 2002.

AHA Central Office"Coding Resources" includes information on the following classification systems:

ICD-9
ICD-10
HCPCS

Medicare HIPAA Documents (PDFs) include:

Implementation of HIPAA Transaction Standards - Overview and Specific Instructions for Implementing the Inbound Claim
X12N 835 Payment/Remittance Advice
Guidance on HIPAA Health Care Claim and COB; Implementation of the HIPAA Transactions
Implementation of the HIPAA Eligibility Benefit 270/271 Transaction Standard
HIPAA 837 Health Care Claim Implementation Direction
HIPAA Testing and Certification Requirements and Date Changes
HIPAA Implementation of the NCPDP Telecommunications Standard Version 5.1 and the Equivalent Batch Standard Version 1.1 for Retail Pharmacy Drug Transactions
Reporting of Admission Dates/COB Transactions
Claims Status Inquiry/Response
Transaction Certification and Testing
Timelines for HIPAA Requirements
Generating an Outbound COB X12N 837 (4010)
Remittance Advice Coding and Completion
Model Compliance Plan
Provider Taxonomy
Provider Notification
...& more

Articles

Get Your NPI ASAP! by Ken Terry, Medical Economics, December 1, 2006
If you delay obtaining a national provider identifier number, you may be in for a world of hassles.

Take a Number by Heather B. Hayes, Government Health IT, November 13, 2006
Providers must obtain their National Provider Identifier by May 2007, but confusion, IT challenges and privacy concerns are slowing the program.

Doing a Number on Providers by Joseph Conn, Modern Healthcare, May 30, 2006
Though it's not an imminent problem, the compliance deadline for adoption of the national provider identifier is now less than a year away, and, given the enormity of the task, industry experts are warning it should already be on the "to do" lists of healthcare executives and technology professionals.

Identity Crisis? Renewed Debate Over National Patient ID by Joseph Conn, Modern Healthcare, May 30, 2006
Since February, there have been several public and private meetings at which, once again, US healthcare IT cognoscenti have discussed establishing a discrete healthcare ID number for each patient.

Is There an Identity Crisis? by Beckie Kelly Schuerenberg, Health Data Management, January 2006
Now, many face a new HIPAA migraine: Complying with the rules requiring standard identifiers for providers, health plans and employers.

ICD-9: What's Changed by Barbara F. Halenar, Medical Economics, October 7, 2005
We tell you what the new ICD-9-CM codes are, which ones were revised, and which were deleted.

ICD-10 Standards: Code Talkers by Fred D. Baldwin, Healthcare Informatics, October 2005
Some are eager, others much less so, for the ICD-10 standards to take effect.

A Law's New Tech Snafus by Mindy W. Toran, Risk and Insurance magazine, April 1, 2005
Just when the medico-insurance community was adjusting to the complexities of HIPAA, here comes news of yet another complication. This time it comes in the form of mundane electronic claims attachments.

The HIPAA Prescription for Healthcare – Why Isn't It Working? by D'Arcy Guerin Gue, with Randa Upham, Health Management Technology, September 2004
The HIPAA history book recorded snail-paced startups on privacy initiatives by covered organizations followed by last-minute sprints to the “almost” finish line, and security compliance may well mirror this pattern.

HIPAA's Promise Undermined by Claims-Processing Tangle by Joel B. Finkelstein, American Medical News, September 13, 2004
Rules that were supposed to make life easier are vexing many physicians and slowing claims payment.

Standard Transactions and Code Sets: Practical Steps and Strategic Options by Mike Doscher, HealthLeaders, November 3, 2003
By mid-October payors were to comply with all the HIPAA-mandated transactions. According to Phoenix Health Systems' Summer 2003 Quarterly HIPAA Survey, however, only 62 percent of payors expected to be ready with all mandated transactions. There are many challenges that the late entrants into testing will encounter, but there are options for dealing with them.

Getting Claims Paid in a HIPAA World by Joseph Goedert, Health Data Management, October 3, 2003
Physician practices not ready for the transactions rule have ways to get their compliance efforts on the fast track.

Clinical Standards in Health Care: Are we destined to make the same mistakes as HIPAA? by Shannon Koss, Health Data Management, June 2, 2003
Congress enacted HIPAA in 1996 and we are just now seeing the implementation of the initial standards for Privacy and Transactions. With the implementation deadline for Privacy having just passed, and the Transaction deadline looming, it has become clear that the standards process and what it takes to actually implement standards is far more complicated than any of its proponents appreciated back in 1996.

Health Agency Closes Gap on Verification by Dibya Sarkar, Federal Computer Week, May 5, 2003
For the past year or so, some HHS Indian Health Service (IHS) offices and facilities have been using a free, hosted Web-based verification system developed by two employees from another IHS unit, that offers instantaneous verification of a patient's insurance coverage. HHS' Indian Health Service (IHS) Resource and Patient Management System (RPMS) was updated only monthly and eligibility usually couldn't be verified until 24 hours later, meaning IHS units couldn't bill insurance companies or government programs for services.

Multi-Stage EDI Testing Critical for Transformation to Standards-Based Automation of the Revenue Cycle by Michael Doscher, HealthLeaders, April 14, 2003
The dimensions of the challenge to implement the HIPAA prescribed transactions are formidable. Extensive testing will be the industry's key to the success of its short- and long-term venture into eCommerce.