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Transactions and Code Sets: For Geeks Only?
by D'Arcy Guerin Gue, Exec. Vice President, Phoenix Health Systems
About a year ago, a poll of 14 healthcare IT consultants and CIOs
revealed that seven didn't know what transactions and code sets
were, four knew they "had to do with EDI" and three could
actually define the term. Admittedly, the poll was less than scientific,
having been casually taken among industry acquaintances on the busy
floor of the 2000 HIMSS Conference. Still, its outcome underscores
how many healthcare administrative and IT professionals historically
have left the subject of electronic data interchange to the EDI
"geeks" of healthcare.
HIPAA won't let them stay off the hook for long. With the publication
of the final Transactions and Code Sets Standards (TCS) in August,
2000, many healthcare professionals who once couldn't tell ASC X12N
from ASCII text, now need to learn enough to guide, or at least
support, HIPAA TCS implementations within their organization.
WHAT ARE TCS?
Transactions and Code Sets Standards are data models that have
been defined and approved by agreement of the members of various
independent organizations that focus on supporting the electronic
transfer of Information. These include Health Level 7 (HL7), the
American Society for Testing & Materials (ASTM), and the Accredited
Standards Committee's Insurance Subcommittee (ASC X12N). (Now you
know what ASC X12N is.) The TCS models, or standards, define how
electronic data is to be structured to accurately and consistently
represent data in paper-based documents. The standards designate
specific communication protocols for data formats and sequencing,
data definitions, software and hardware, to ensure that electronic
interchange of data can occur between disparate computer systems.
WHY STANDARDS?
Until now, the country's 1500+ healthcare payers have employed
a huge variety of formats and data requirements to handle claims
and other transactions. The industry consensus has been that this
lack of a single standard has created a national transaction environment
that is unwieldy, error-prone, and unnecessarily costly. Adoption
of the HIPAA-mandated TCS standards is expected to provide "administrative
simplification" to speed up and streamline business processes,
reduce errors, and lower costs. It is also likely to substantially
increase the use of EDI in healthcare, moving the country towards
eventual replacement of paper-based transactions with EDI.
TCS "SPECS" UNDER HIPAA
Under the final TCS rule, health plans and clearinghouses must
be able to accept and generate data transmissions that meet the
rule's standards by October 16, 2002 (plans making $5 million or
less have another year). The rule incorporates ASC X12N standards
for electronic transactions including:
- healthcare claim or encounter (837)
- referral certification and authorization (278)
- claim payment and remittance advice (835)
- health claim status (276/277)
- coordination of benefits (837)
- health plan eligibility (270/271)
- enrollment/ disenrollment in a health plan (834)
- health plan premium payments (820)
The rule also requires the use of standardized coding to represent
the data to be transmitted. Code Sets include:
- Current Procedure Terminology (CPT-4)
- International Classification of Diseases, 9th Revision, Clinical
Modification
(ICD-9-CM)
- HCFA Common Procedure Coding System (HCPCS)
- Code on Dental Procedures and Nomenclature, 2nd Edition (CDT-2)
- National Drug Codes (NDC)
WHAT...ME WORRY?
Payers and clearinghouses have no choice -- they must comply. They
are the only entities who, if non-compliant, have been marked for
hefty civil penalties. However, non-complying providers, vendors
and others will pay the price of reimbursement delay, client/patient
dissatisfaction, and other process problems. Providers don't have
to comply with the TCS Rule -- IF they don't transmit transactions
electronically. But, any provider that uses EDI is required to comply.
Most healthcare providers recognize that they need HIPAA compliance
steering committees and task forces to undertake internal awareness,
assessment and implementation planning efforts. But many are focusing
on privacy and security requirements, assuming (or hoping) that
their vendors and clearinghouses will solve the TCS puzzle. Electronic
transactions issues should not remain a puzzle -- let alone an unknown
-- among provider IT and administrative leaders. A major focus of
their efforts must be determining, department by department and
system by system, how TCS will impact their operations.
WHAT TO DO?
Strategic questions should be asked and answered: If the organization
is still using paper-based transactions, is this the time to upgrade
to electronic? If it has elected to use electronic transactions,
should it rely on clearinghouses or adopt its own solution?
Tactical questions must be answered: Is the organization electronically
collecting ALL data required by the TCS Rule, or is there some missing?
(There often is.) How will the patient registration, collections,
medical records, insurance verification and other affected areas
structure TCS implementation and coordinate timing with payers and
others? Does anyone internal know enough about EDI transactions
and code sets to oversee the assessment and implementation -- or
should an outside expert be brought in?
That person may not be you. Even if it isn't, if you have read
this far, you probably care or expect to be held accountable for
your organization's HIPAA compliance. In that case, you are making
a mistake if you don't learn more about TCS than this HIPAAlert
issue offers.
Our absolute, bare minimum recommendation: read the real thing
-- the full text of the Transactions and Code Sets Rule. Then go
to the standards organizations' websites and soak up the atmosphere.
Take a good look at the implementation manuals available free on
the Washington Publishing Company site. Consider the areas in your
organization which may be affected and familiarize yourself with
related systems, processes, costs. Then, begin to think about and
ask the questions listed above.
Pretty soon, we think you'll be asking -- and hopefully answering
-- many more.
D'Arcy Guerin Gue is Executive Vice President of Knowledge Services
and Business Development for Phoenix Health Systems, and publisher
of HIPAAlert and HIPAAdvisory.com.
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