Jonathan Showalter, of Blue Cross and Blue Shield of Nebraska, refers us
to the HIPAA implementation guide for Institutional Claims (X12 837
Version 4010) at the SV2 (Institutional Service) segment within the 2400
loop. SV204 (Unit or Basis for Measurement Code) is a required element,
and may assume the code values UN (Unit) or F2 (International Unit) when
reporting drug dispensation. As to the latter, International Unit,
Jonathan inquires: "What's that mean? Does that mean I can use cc's,
grams, etc?"
If the guide wanted us to explicitly describe a drug's dosage amount
with a metric amount, the Service line loop would have provided for
that. Most, if not all, prescription or over-the-counter drugs can be
described by the FDA's National Drug Code (NDC) - a kind of universal
product identifier. The NDC identifies, among other things, the
specific strength of the drug product, which often is in terms of
milligrams of this, or milliliters of that.
Therefore, there's no need for the strength to be provided since HIPAA
forces the drug to be identified by the NDC in the SV202 composite.
Once the drug has been completely identified using the NDC, you just
have to say how many *units* (pills, capsules, etc.) were dispensed, in
the required SV205 Quantity element.
The HIPAA Final Rules (August 17, 2000) do acknowledge that "the NDC
does not always allow identification of partial vials (that is, when a
single vial is used among multiple patients), we note that although this
may be true with certain NDC codes, the transaction standards allow the
reporting of dosage units for the NDC." In this rare case, if the
drug - such as blood clotting factors - is not in unit dosage form, its
strength can be expressed in WHO (World Health
Organization) International Units, which the 837 Institutional guide
provides for with code F2 - International Unit - in SV204.
Perhaps someone should take up Peter Randlev on his suggestion that the
underlying X12 definition of the code be cleaned up. But the definition
in the HIPAA guideline, "Dosage amount is only used for drug claims when
the dosage of the drug is variable within a single NDC number (e.g.
blood factors)," seems adequate.
While we're on the topic of HIPAA, EDI-L's own resident HIPAA legal
expert, another Jonathan - Jonathan Allen - assures us "the HIPAA
guidelines do not comply with the 'Compliance in X12' Technical Report -
at what level is immaterial to the principles involved, as the DoD case
shows - and so those making and setting the rules have laid themselves
open to the possibility of costly delays and litigation."
As with any man-made artifact, the HIPAA guidelines do indeed have
ambiguity (as the "International Units" incident above attests) or
outright errors. None of us is perfect, including the authors of the
guideline or the HIPAA rules themselves. Nor, more importantly, would
perfection be cost-effective as we're not talking about jet engine
turbine blades here. There are plenty of chances to correct errors in
the HIPAA business documents (e.g., claims, payments, eligibility
benefits, claim status, or enrollment) with phone calls, letters and
appeals; the worst case is that payment is delayed, which insurance
companies have raised to a high art, anyway - with or without HIPAA.
HL7 clinical EDI, on the other hand, is used to support diagnosis and
treatment, and concomitantly must provide fewer opportunities for
ambiguity.
The HIPAA deadline gives serious professionals - from providers, payers,
clearinghouses, and software vendors like FORESIGHT - an opportunity to
collaborate in goodwill to simplify the administration of our nation's
healthcare system. Putting aside questions of HIPAA's dubious
constitutionality, whereby Congress delegates rule promulgation to the
Secretary of Health and Human Services, the result may nonetheless be
timelier payments with less paperwork and hassle. But I don't think
Jonathan Allen is concerned with notions of Federalism and subsidiarity;
instead he's probably on his kick of painting the darkest picture
possible of nitpicking complainants mired in the picayune minutiae of
all-blank ISA fields.
Just last week, one of our customers pointed out that the EDISIM
Analyzer warned about a missing - though required - element in their
data when it was run against the HIPAA 837 Professional Claims guide.
It seems that the NM1 in the Other Payer Patient Information loop
(2330C) has the NM103 (Individual last name or organizational name)
marked as "Required," though that makes no sense considering the NM1 in
this case is used to provide additional identifiers for an already known
entity. But since the HIPAA guide said NM103 was required, the EDISIM
Analyzer dutifully reported the omission. No corrections or warnings
have been noted for this issue yet on the HIPAA errata site maintained
by the Washington Publishing Company at http://errata.wpc-edi.com/.
Lawsuits and litigation could have ensued, but Providence intervened and
Jonathan Allen's "Waterworld" of scarcity-thinking and litigation was
headed off. Instead, calm minds decided this was a small error in the
documentation. The customer and FORESIGHT will further investigate the
matter with X12N, WEDI and Washington Publishing, and if most see it as
we have, the errata process can be started. Teamwork, collaboration and
goodwill, as always, will ensure progress toward our common goal in this
consensus based standards effort.
William J. Kammerer
FORESIGHT Corp.
4950 Blazer Memorial Pkwy.
Dublin, OH USA 43017-3305
+1 614 791-1600
Visit FORESIGHT Corp. at http://www.foresightcorp.com/
"Commerce for a New World"
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