>>> "Kumar Sivaraman" <[EMAIL PROTECTED]>
05/22/02 02:01PM >>>
Hi All,
On the subject of HIPAA code
sets I wish to request your comments on the
following.
Problem
statement
-----------------
HIPAA mandates that in order for a
transaction to be HIPAA-compliant, the
value of certain data items must be
validated to be contained in an instance
of a code set that was "valid
within the dates specified by the organization
responsible for maintaining
that code set".
An "instance" of a code set contains the set of all
valid values for a
specific data item at a specific point in time - for
example, the set of all
valid zip codes for the US as at 1-Jan-2000 is
contained in the code set
instance published by the issuing authority for
zip codes with an applicable
date of 1-Jan-2000.
The authorized
issuing authority for a specific code set is responsible for
making new
instances of that code set available to parties which require to
validate
against that code set.
There is necessarily a delay between the actual
publication date of a new
instance of a code set, and the installation of
that code set instance on a
specific computer system ready for use
validating transaction data values.
This gives rise to the likelihood
of the following problem occurring
regularly in operational
systems:
1. A transaction set is originated in trading partner A
(TP-A).
2. A data value in that transaction set is validated by TP-A
to be correct,
as it is contained in the current code set instance in use
by that trading
partner.
3. TP-A transmits the transaction set to
TP-B.
4. TP-B validates the same data value, which fails validation
because a
different code set instance is in use by
TP-B.
Questions
---------
a) How does the healthcare industry
address this issue?
b) Do code set issuing authority indicate any time
frame by which a new code
set (or a new value in a code set) becomes
effective and ready for use in
transactions?
c) The magnitude of this
is much bigger for clearinghouses. How would they
address
this?
Thanks,
Kumar Sivaraman
Business Analyst -
Standards
SeeBeyond Technology Corp.
|-----Original
Message-----
|From: Dhandapani, Palani (Cognizant) [
mailto:[EMAIL PROTECTED]]|Sent:
Tuesday, May 21, 2002 11:06 AM
|To: Winston, Mike K.; Dhandapani, Palani
(Cognizant);
|[EMAIL PROTECTED]; '[EMAIL PROTECTED]'
|Subject: RE:
Date of service
|
|
|Interesting.
|
|Coming to claims that are
already in the system/application
|prior to HIPAA
|switch being turned
on, we may not be able to apply HIPAA edits for two
|reasons : 1. Claims
may have non standard code sets that may not pass
|Level-5 HIPAA edits
(code set validation) 2. The claim may be
|have come in
|the
non-standard format, so there is no need to apply Level-1
|to
Level-6
|edits. Folks, please correct me if I am wrong.
|
|Now, I
have one question to the Group:
|
|What are the different scenarios for
processing claims after
|Oct 2003? I
|have listed here some of them.
Please add if I have missed
|anything or if I
|am
wrong.
|
|Scenario-1 : Claims with standard code sets in X12 4010
format
|
|Option : No problem as the HIPAA compliant application will be
able to
|handle it happily.
|
|Scenario-2 : Claims with Standard
codes in Paper format
|
|Option-1: Accept, adjudicate and send Paper
EOB. Only Level-5
|HIPAA Edit in
|the application.
|Option-2: Send
835 ERA, if provider requests. (Make sure all minimum
|required
information is available for generating 835 as
|response to
Paper
|claim). Level-5 edit in the application and other HIPAA edits
|for 835 at the
|outbound side.
|
|Scenario-3 : Claims with
non-standard codes in Paper format.
|
|Option-1: Accept, cross walk,
adjudicate and send paper EOB.
|Option-2: Notify providers to stop sending
claims with
|non-standard codes
|from a cut-off date prior to HIPAA
compliance date.
|
|Am I missing anything
?
|
|Thanks
|Palani
|Cognizant Technology
Solutions
|201-678-2772
|
|-----Original Message-----
|From:
Winston, Mike K. [
mailto:[EMAIL PROTECTED]]|Sent:
Tuesday, May 21, 2002 7:46 AM
|To: 'Dhandapani, Palani (Cognizant)';
[EMAIL PROTECTED];
|'[EMAIL PROTECTED]'
|Subject: RE: Date of
service
|
|
|Thanks,
| I do not see how Hipaa can expect edits to
be applied to a
|claim adjustment
|when the original claim was
processed before the edits were
|established.
|Does Claim generation
refer to the date the claim was generated by the
|provider, if so then
claims already in our system prior to the
|Hipaa switch
|being turned
on do not have to meet the Hipaa edits. Correct?
|
|
|Mike
Winston
|Business Systems Analyst
|Trigon ISD
|Ph (804)
354-4521
|Fx (804) 678-0452
|[EMAIL PROTECTED]
|
|This message,
including files attached to it, may contain confidential
|information that
is intended only for the use of the ADDRESSEE(S) named
|above. If you
are not the intended recipient, you are hereby
|notified that
|any
dissemination or copying of the information is strictly
|prohibited.
If
|you have received this message in error, please notify the
sender
|immediately and delete the message from your system. Thank
you.
|
|
|
|
|
|
|> -----Original
Message-----
|> From: Dhandapani, Palani (Cognizant)
|[SMTP:[EMAIL PROTECTED]]
|> Sent: Tuesday,
May 21, 2002 10:15 AM
|> To: Winston, Mike K.;
[EMAIL PROTECTED]; '[EMAIL PROTECTED]'
|> Subject:
RE: Date of service
|>
|> There are two components here. Medical
code sets and
|NonMedical code sets.
|>
|> For Non-medical
code sets, the Data of service is the
|reference. So we
|> should
use the medical codes that are valid on the date of service.
|>
|> For Non-medical code sets, the date of Claim generation is
|the
reference.
|>
|> Please refer to the following
regulation:
|>
|> 162.1000
|>
|> (a) Medical data
code sets: Use the applicable medical data code sets
|> described in
section 162.1002 as specified in the implementation
|> specification
adopted under this part that are valid at the time the
|>
health
|> care is furnished.
|>
|> (b) NonMedical data code
sets: Use the non medical data code sets as
|> described in the
implementation specifications adopted under
|this part
|>
that
|> are valid at the time the transaction is initiated.
|>
|> Hope this helps.
|>
|> Thanks
|> Palani
|>
Cognizant Technology Solutions
|> 201-678-2772
|>
|>
|> -----Original Message-----
|> From: Winston, Mike K. [
mailto:[EMAIL PROTECTED]]|>
Sent: Tuesday, May 21, 2002 6:37 AM
|> To: [EMAIL PROTECTED];
'[EMAIL PROTECTED]'
|> Subject: Date of service
|>
|>
|> I know this was discussed, but I want to confirm that
|opinions
have not
|> changed. When Hipaa is in effect we are planning on using
|the claims Date
|> of
|> Service to determine if the claim
needs to be fully compliant or not,
|> example: Claim was
submitted prior to Hipaa live date with
|a "Homegrown
|> code" the
835 goes out after Hipaa is implemented with the
|non-compliant
|>
code. or Claims that were not subject to any crossfoot edits prior to
|>
hipaa
|> if adjusted will be sent out on the 835 but will not
crossfoot.
|>
|> We are making the logic based on the claims date
of service not the
|> processed date. Any thoughts?
|>
|>
Mike Winston
|> Business Systems Analyst
|> Trigon ISD
|> Ph
(804) 354-4521
|> Fx (804) 678-0452
|>
[EMAIL PROTECTED]
|>
|> This message, including files attached
to it, may contain
|confidential
|> information that is intended
only for the use of the
|ADDRESSEE(S) named
|> above. If you
are not the intended recipient, you are
|hereby notified
|>
that
|> any dissemination or copying of the information is strictly
|prohibited.
|> If
|> you have received this message in error,
please notify the sender
|> immediately and delete the message from your
system. Thank you.
|>
|>
|>
|>
|>
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