Members of the Committee, Ladies and Gentlemen;
Thank you for this opportunity to testify to you on UHIN’s experience with reduction of local codes. I am Bart Killian, the COO of UHIN. I have been with the company since it’s inception and have been deeply involved in the efforts to implement EDI standards in the state of Utah.
UHIN first began looking at codes in our very first standard – Anesthesiology billing. Since then we have been involved in many coding issues some of which I will share with you today.
The primary problem we have had with the proliferation of local codes is that, in these cases, the organizations responsible for various national code lists have not been responsive to the needs for certain codes. As a result, payers (and sometimes providers) have created their own codes and agreed to definitions of those codes with their trading partners.
The examples I’m about to share with you demonstrate these points: Commercial payers and the coding needs of providers who are not physicians may be overlooked by the administrative bodies that oversee HCPCS and CPT codes. From their perspective, such coding needs fell outside of the purview of their code lists. However, ignoring ‘outside’ coding needs has resulted in a proliferation of local codes which we will now have to migrate away from. The examples I’m about to share all involve the standardization of local codes into one code set (for each example). UHIN has been attempting to penetrate the administrative bodies responsible for handling the targeted code lists in order to petition the addition of these codes but we have not been successful to date.
Please take a moment to turn to UHIN Standard #28 – Home Health. This is a fairly lengthy standard primarily because of the need for detailed coding in areas of home health that Medicare does not pay for and that often does not utilize physicians to provide the services. Home Health is a rapidly expanding new specialty in health care and many commercial plans include some home health coverage. In the HCPCS/CPT code list there are primarily only generalized codes. The use of these codes – colloquially termed ‘dump codes’ - results in either extensive attachments or back and forth phone calls, all of which require manual intervention. UHIN’s goal was to create a code list that was useful to all the UHIN payers that would eliminate the need for manual handling of the claims. The Utah State Medicaid program graciously opened up their Y-code list and assigned new codes as detailed by the UHIN Standard. UHIN understands that the Medicaid Y-codes will eventually be merged into a single HCPCS (or other) code list but for now, it was an acceptable solution to all the parties involved.
There are three areas that UHIN found needed more extensive coding: Home health care nursing visits, home infusion services, and drugs billed with IV home infusion services/supplies. In the case of the first area – nursing visits – it was necessary to create a list of revenue codes and their associated units (Standard #28, Appendix A) as payers were using different revenue codes with different units for the same nursing visit services. In the case of infusion services and supplies it was necessary to create two code lists. Some providers are contracted to bill itemized and some must bill globally. The itemized code list (Standard #28, Appendix B) includes codes for enteral and parenteral nutrition, nutrients, IV supplies, nutrition assessment, and pumps. The global code list (Standard #28, Appendix C) contains those codes that were identified to accomplish global billing without attachments. For billing drugs, UHIN has agreed to use NDC codes as per the 4010 implementation guides. The bulk of this Standard lists the various Y-codes and their definitions.
In 1998 the Utah State Legislature passed a law requiring the uniform billing of dietary products such as PKU foods for infants. In this case, these dietary foods are often billed through the hospitals pharmacy on the institutional bill. There are no detailed HCPCS codes (Medicare provides very little coverage for infants) so the claim was usually initially denied by the commercial payer. While all payers in Utah do cover medically necessary dietary products, the dump code indicating a dietary product was not specific enough to indicate which product was being billed for. Hence, service lines using the generic dietary product code were usually denied, and had to be subsequently manually handled by the provider in order to get the payer to pay for the product(s). Both payers and providers agreed that a more detailed code list was in order.
Originally, the Insurance Commissioners office was going to just create codes on their own (another example of how local codes get started) but UHIN staff alerted them to HIPAA’s mandate of no local codes. Because the State law required some action prior to the implementation of HIPAA the insurance commissioners office agreed to allow UHIN to convene a Standards subcommittee to explore the billing needs and to propose codes to meet those needs. This resulted in the development of UHIN Standard # 27. Again, Utah State Medicaid opened up their code list to the subcommittee. A cursory review of the code list indicates that this is a highly detailed code list. Eventually, it is possible that we might migrate to UPNs but neither payers nor providers were ready to do that at this time. The effective date of this Standard was February 12, 1999.
Utah’s population and health care services are largely concentrated on the Wasatch Front – a 4 county area centered in the north central portion of the state. The remaining 25 counties – approximately 80% of the land mass are rural, some having approximately 1000 persons in the entire county. Health care, particularly for specialties, can be far and few between in these areas. Telehealth is being developed as a means of providing health care services to isolated rural populations.
Providers approached UHIN with a request to develop a unified coding method for billing telehealth. At first payers were not particularly interested in supporting new codes for these services. However, providers convinced them that (1) billing would be more accurate (hence payment would be more accurate) and (2) it would be to payers advantage to know when telehealth is being billed as they could then keep track of this service in their actuarial departments. UHIN Standard #26 is the outcome of this effort. During the discussion it became clear that telehealth is more complex that initially thought. The subcommittee identified two areas of telehealth that needed additional billing clarification: teleconsultation and store-and-forward telehealth. To make a long story short, it was finally determined that three additional modifiers are needed to clarify telehealth billing: one to indicate when a teleconsultation (face-to-face), one to indicate that a referral presentation, and one to indicate teledata/teleradiology. The use of these codes began on July 1, 1999.
Ambulatory surgery center (ASC) billing is notorious for sending attachments with claims. When we initially began work on Standard #29 we thought we were in for something more like our home health experience – lots of detailed codes. However, after extensive discussions, the ASC attachments issue largely boiled down to two issues: whether a supply was being billed at cost or not. Hence, two modifiers were proposed to handle this need.
UHIN is committed to complying with HIPAA and using national code lists. However, it is also necessary that the industry be able to comply with state laws and to meet emerging business needs. UHIN has attempted on several occasions to apply to the various organizations that control the HCPCS and CPT code lists but without success. It is our hope that, with the implementation of HIPAA, that these organizations will begin to meet the coding needs of the industry at large, rather than just their constituents. For now we are using Medicaid Y-codes. We hope that, in the process of merging the Y-codes into the HCPCS/CPT code lists, our business needs will be met. All of the coding issues identified today are shared by other states and we believe there is a need for these codes at a national level.