Electronic standards on the horizon for coding and submitting claims
HCFA publishes proposed regulations, analyzes comments
Despite its own problems dealing with the Y2K dilemma, the Department of Health and Human Services, with significant help from the Health Care Financing Administration, is set to streamline the health care industry by implementing electronic standards for coding and submitting electronic health claims.
With the comment period closed since July, HCFA now is prepared to finalize the regulations, according to a HCFA spokesman.
"We’re in the process of analyzing the comments," says the spokes man. "As soon as we analyze them and can respond to the comments, we will issue a final regulation, which will align how providers will implement the regulations as well as set a deadline."
It’s likely the deadline will be two years after the effective date of the final regulation, so home infusion providers may have close to three years before the regulations are mandatory.
"It would be several months [before final regulations are posted] because it takes that long to go through the comments and there is a lot of national interest in these," notes the HCFA spokesman. "The nature of the comments also dictates how fast we can issue the final regulation."
Potential hang-ups
Bruce Rodman, chair of the Home Infusion EDI Coalition (HIEC) and reimbursement section manager for Abbott Park, IL-based Abbott Home Infusion Services, recently addressed HCFA regarding concerns the coalition had about simplification of the regulation.
"I am commenting with intent of improving the final rules in such a way that it becomes possible for home infusion providers and payers to achieve administrative simplicity for our insurance-related transactions," Rodman told HCFA. "If our needs are not incorporated into the final rules, it will not be possible for our home infusion industry to achieve the objectives."
Rodman notes that the home infusion industry is critical to the implementation of any standards because of its already burdensome insurance administrative process.
"Home infusion is estimated to be a $4 to $5 billion industry in the United States," according to Rodman. "Historically, home infusion provi ders have been burdened with what is widely recognized as the most difficult and least efficient insurance administrative process in health care. Home infusion insurance claims are also very expensive for insurers to process."
Such problems arise because of the lack of common standards for home infusion claims, notes Rodman, as well as the fact that most home infusion claims are submitted on paper. Submitting claims also is burdensome because of the lack of a national standard for coding home infusion services. As a result, Rodman points out that home infusion providers must custom-code claims for nearly every insurer.
Recommended revisions
While in favor of the proposed rules as a whole, HIEC’s suggestions to HCFA included specific recommendations in the following areas:
1. Electronic format.
HCFA recommended the adoption of NCPDP Telecommunication Claim Version 3.2 or equivalent NCPDP Batch Standard Version 1.0 for "retail drug" health care claim and equivalent encounter transactions, to which the HIEC responded, in part:
"Home infusion providers need to submit claims by only a single electronic format to obtain maximum administrative efficiency. This format should be the X12 claim standard. The NCPDP Version 3.2 and Version 1.0 standards will not support a home infusion claim because the transaction does not support compounded drug claims and it also does not support claims for the supplies, pumps and clinical pharmacy services of a home infusion provider. The X12 standard supports claiming of all services of a home infusion provider. "
2. Placement of codes.
In its proposed regulation, HCFA stated: "Administrative functions necessary to process and facilitate claims by health insurers can be achieved by using administrative’ codes placed in fields other than those used for medical diagnosis and procedure codes or by attaching a modifier to a medical code."
HIEC’s response noted: "To suggest codes needed to charge for administrative functions, such as the administering of a health care service, are to be placed in fields other than those used for medical diagnosis and procedure codes, or by attaching a modifier to a medical code, is simply ludicrous if this means a provider cannot bill a charge for all of its services."
Rodman notes that home infusion claims are often submitted to private insurers for per-diem services under terms of a contract between the provider and payer, and the only way to encode such a charge is through assigning a procedure code.
"At a minimum, the final rule should be revised to guarantee that a health care provider is not prohibited from submitting a claim which codes and charges for all of its services, including administration of the health service expressed as a per diem charge, as well as administration of drug therapy," notes Rodman.
3. Coding standards.
While the HIEC developed and maintains a national coding system for home infusion products and services, any new electronic submission standards could prove to undermine its work. With this in mind, Rodman has recommended that HCFA include the HIEC Home Infusion Services National Coding System in the standards.
4. National review process.
HCFA recommends there be a "national process established for reviewing and approving codes that are needed by any public or private health insurer." Codes are currently maintained by HCFA and other groups through an Alpha-Numeric Editorial Panel, which meets three times per year in meetings not open to the public.
HIEC responded to the proposal by stating that health care providers, as well as any other interested parties, must be included in the process of reviewing and approving codes.
HCFA also had proposed that temporary codes be established as needed for use by all health insurers.
Rodman told HCFA: "We object to the proposed process for establishing temporary codes because it provides HCFA with sole decision-making authority over establishing these codes. While we have respect for HCFA’s area of expertise in administration of government health insurance programs, we believe HCFA is not qualified to make decisions on coding used for the trading partner relationship between health care providers and non-government insurers."
HIEC made several other technical suggestions to the proposed regulations. You can obtain a copy of Rodman’s presentation to HCFA on behalf of HIEC by e-mailing him at [email protected].
HCFA also has introduced a proposed rule that would require every health care provider to acquire an alphanumeric identifier for use when filing claims for reimbursement by public and private insurance programs. HCFA contends that the currently required multiple provider numbers slow the payment process, increase costs, and result in a lack of coordination. The proposed rules are two of the administration’s simplification steps provided for in the Health Insurance Portability and Accountability Act of 1996.
Under the proposed ID number rule, all health care providers would apply for an eight-digit identifier to use when processing electronic claims. The identifier would remain with the provider, even if it moves or changes specialties.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content