Standards for Electronic Transactions and Code
Sets
III. Analysis of, and Responses to, Comments on the Proposed Rules
(cont.)
C. Proposal to Adopt Modifications to the Standards Adopted in
the Transactions Rule
We proposed in CMS-0005-P (67 FR 38050) to adopt modifications
to certain standards adopted in the Transactions Rule (65 FR 50312).
The modifications we proposed were the result of the DSMO process
to maintain standards adopted by the Secretary and to process requests
for adopting new standards or modifying adopted standards. (The
DSMO process is described in section I. C. of this rule.)
The versions of the Addenda adopted in this final rule are referenced
by the suffix "A1" and dated October 2002. It is important
to note that these versions become final with publication of this
final rule. Consequently, the October 2001 date is revised to October
2002 to reflect the final versions of the adopted Addenda.
D. Composition of the Addenda
Addenda are defined as modifications to items in the implementation
specifications that could be considered impediments to implementation.
They are first published in draft form and go through the rulemaking
process before becoming final.
Two hundred thirty-one change requests were submitted to the DSMOs
for consideration. Eighty-five were returned to submitters because
the Implementation Guides already met the specific business need,
or the need was not well substantiated; 21 were determined to be
unnecessary for initial implementation and were, therefore, recommended
for future changes; six were withdrawn by their submitters; and
seven were referred to the Secretary as policy issues requiring
resolution. The remaining 115 change requests were approved by the
DSMOs and comprise the various Addenda.
Forty-eight of the 115 change requests were maintenance items to
correct minor errors, or provide clarifications in the standards.
Maintenance changes are technical corrections made by DSMOs to correct
typographical errors or other non-substantive changes. Maintenance
changes exclude activities related to the adoption of a new standard
or implementation specification or modification to an adopted standard
or implementation specification. Maintenance changes are typically
changes that are obvious to readers of the Implementation Guides,
are not controversial, and are essential to implementation. These
maintenance items are the result of DSMO change requests that were
approved and recommended for adoption
via the DSMO process. Therefore, we are not including a discussion
of them in this final rule.
The remaining 67 of the 115 change requests were for substantive
modifications to the standards, and they are detailed below.
E. Proposed Modifications to the Standards
- Changing usage of data elements from required to situational
(about 20 percent of total requested changes).
Required usage of data elements means that particular data elements
must be used every time the transaction is conducted. Situational
usage of data elements means that,
CMS-0003/5-F Page 47 when certain specified situations or conditions
exist, particular data elements must be used when the transaction
is conducted. Those who submitted DSMO change requests pointed out
several data elements for which the adopted standards required usage
in all cases, but that was only needed in certain situations. Usage
of these data elements was made situational in the Addenda, with
the situations explicitly defined. Examples follow:
- Many health plans store Healthcare Provider Taxonomy Codes when
health care providers enroll in the health plan, so there is no
need to send this information on every claim. Healthcare Provider
Taxonomy Codes are data elements that identify the type, classification,
and specialization of providers furnishing health care. The NUCC
maintains these codes. The Washington Publishing Company makes
the Healthcare Provider Taxonomy Codes available on its website
(http://www.wpc-edi.com). The Healthcare Provider Taxonomy Codes
now will be reported only when claim adjudication is known to
be impacted by the presence of the code.
- In another case, "date last seen by physician" (used
for certain physical therapy claims) is needed only by Medicare,
so usage was changed from required on all claims, to required
"when known to impact the payer's adjudication process."
- Removal of certain data elements (about 20 percent of
changes).
Several data elements were removed because they do not appear to
be needed by any covered entity.
- Allowing certain information to be reported via external
code sets rather than via data elements defined in the transaction
(about 20 percent of changes).
ZIP codes, maintained by the U.S. Postal Service, are an example
of an external code set. Revisions and updates for transaction data
elements adopted by the Transactions Rule must go through the DSMO
change request process, while revisions to external code sets require
requesters to submit requests to the organizations that maintain
the code sets and are not subject to the DSMO review process.
There were several instances where external code sets could be
used to indicate certain data elements. The replacement of data
elements with external code sets will allow the maintainers of those
external code sets to update the codes more easily, as opposed to
having the DSMOs make changes to the standards themselves. Two external
code sets adopted by the Addenda are special program indicator codes
and newborn birth weights.
- Adding additional functionality to some transactions
(about 40 percent of changes).
Requesters suggested several additional data elements, codes, or
loops to enable them to perform certain business functions in the
transactions. These included cross-referencing two subscriber IDs
(surviving spouse and dependents) and sending a patient’s primary
care physician number.
F. Comments on the Modifications Included in the
Addenda
CMS-0005-P (67 FR 38050) established the scope for technical comments
by limiting comments to only those items being added or changed
by the Addenda.
Numerous recommendations and suggestions submitted in the comments,
which were not considered critical for implementation, will be considered
for improvements or clarifications to future versions of the implementation
specifications.
Because the comments were technical in nature, relating to specific
data elements and segments, and applied to implementation specifications
that were developed and are maintained by external organizations,
such as the ASC X12N and the NCPDP, the Secretary could not address
all of them directly. Therefore, we analyzed the public comments
received to determine which comments fell
in this technical category. We consulted with representatives from
each of the DSMOs on these technical comments. Some of the technical
comments were referred to the external organizations that develop
the standards, such as the ASC X12N transaction workgroups, for
additional review and consultation.
Comments that did not pertain specifically to the proposed Addenda
were considered and determined to be more appropriately addressed
through the DSMO Change Request process.
The majority of comments we received generally supported adoption
of the proposed Addenda. Most commenters agreed that adopting these
proposed changes is necessary to permit successful initial implementation
of the standards within the industry. The Workgroup for Electronic
Data Interchange (WEDI), the American Hospital Association (AHA),
the National Uniform Claim Committee (NUCC), a number of Medicaid
State agencies, the Health Insurance Association of America (HIAA),
the Blue Cross Blue Shield Association (BCBSA), and the American
Medical Association (AMA) were among the numerous health care providers,
health plans, and professional organizations that submitted comments
expressing support for adoption of the proposed Addenda. Some commenters
suggested that work on the implementation specifications continue
in order to improve the clarity relating to specific situational
data elements and to ensure clear, consistent interpretations and
implementation by health plans.
Commenters unanimously supported many specific Addenda items, for
example:
- The proposal to use existing UB-92 Condition Codes for reporting
special program indicators, as well as UB-92 Value Codes to report
newborn birth weights. These changes would eliminate differences
in the way this information is handled for electronic and paper
submission of claims. It is important wherever possible to follow
the same data development paths for both paper and electronic
submission in order to simplify the capturing and reporting of
billing information.
- The deletion of unneeded data segments and the clarification
of ambiguous usage notes.
We discuss other comments on specific modifications below. They
are organized according to specific adopted transaction standards.
The Addenda are not stand-alone documents. They are supplemental
implementation specifications to the initial standards adopted in
the Transactions Rule. In this final rule, we therefore adopt the
Addenda as part of the standards to which they apply.
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