Mr. Chairman and members of the National Committee on Vital and Health Statistics, I am George Arges, Chairman of the National Uniform Billing Committee (NUBC). On behalf of the NUBC, I want to thank you for the opportunity to testify on the recent DSMO review process. Overall, I would also like to commend the members of our committee as well as all of the other DSMO participants for quickly tackling a number of important issues related to the HIPAA implementation guides on transaction standards.
The DSMO web site allowed the public to submit requests for changes or clarification to the implementation guides. Each of the DSMOs reviewed the change requests and selected those that they felt were important. The NUBC expressed an interest in reviewing approximately 72-change requests. As a result, we convened several conference calls and held a special onsite meeting that also included a co-chair from the X12N 837 workgroup. The NUBC also solicited state UB committee input.
In addition, I participated in various X12 workgroup calls as well as an ad-hoc provider group conference calls spearheaded by Dave Moertel from the Mayo foundation. The ad-hoc group was formed in response to the February 1, 2001 NCVHS hearings. At those hearings, the NCVHS considered several clarifications and corrections to the transaction standards and codes sets. One of the major areas requiring clarification and correction was the use of the National Drug Code. As you know, last September, the NUBC wrote to the Department of Health and Human Services about the problems that could occur in the institutional provider setting with the elimination of the HCPCS J codes. We indicated that there could be costly consequences for hospitals if the National Drug Code was the only code set allowed for the reporting of drugs and biologics on the institutional claim. Again, the NUBC is appreciative of the subsequent NCVHS recommendations to the Secretary of Health and Human Services that allows the continuation of the HCPCS J codes.
The DSMO steering committee met in San Diego last month to present the findings and recommendations of our respective organizations. For the most part, the data content committees carried forward their committee’s recommendations for each of the change requests they selected for review. There were, however, last minute changes by the X12 representatives who unilaterally changed the recommendations from their own X12 group review. We went into this final meeting knowing where each other stood, and when these recommendations were changed at the last minute, it became a source of frustration. It is expected that each of the DSMOs are to consult with their respective constituencies on the change request issues and to then formulate a consensus opinion on behalf of their organizations. Therefore, when the DSMO representatives come together and review each other’s positions, they can be assured that they have developed a majority position that can then move forward for public comment.
Three important change request issues are under appeal and therefore the corrections to the implementation guide are on hold. It is troublesome to know that the needed changes are being held-up pending the appeal. In addition, there is no time limit for follow-through on the appeal process. The DSMOs need to establish an appropriate timeframe for resolution of appeal items. Unless quick resolution occurs to those items under appeal, it can needlessly create costly retooling for many providers and payers. As many of you may recall, our charge was to correct errors, provide guidance and where there was uncertainty as to the requirements, to ensure that the necessary usage requirements are identified and appropriately put in place.
From the NUBC perspective, there are three areas where there still is disagreement.
There were three key areas from the DSMO process that are of major concern to providers: National Drug Code; Physician Line Item Billing; and Provider Taxonomy code usage on the patient bill.
The establishment of the new segment 2410 - Drug Identification for the reporting of an NDC still does not define the situational usage in any practical terms. The note simply states to use the NDC when it is necessary to further define the service provided in SV202.2, which the NUBC views as clearly insufficient.
While the NUBC helped win a victory in reversing the final rule’s discontinuation of HCPCS “J” codes, we need to be vigilant about the wording in the X12 implementation guide. As it stands, the guide’s wording allows the reporting of the NDC whenever the service line item requires greater clarity. This is unacceptable.
The problem with this usage note is that it is not conducive to administrative simplification because it does not explain to the provider the instances under which the NDC will be required. Providers need to know ahead of time the circumstances that will require them to use a NDC. If providers report a HCPCS “J” code and then follow-up with an NDC, this does nothing for simplification of the billing process. Another problem with this is that most hospital charge systems only have the ability to assign one clinical code set number per service.
In the instance of compound or cocktail drugs (mixture of drugs), it would be impossible to indicate the exact NDC code since there are no specific NDCs for these situations.
All situational usage items must take into account how the information is an essential component to the adjudication of the claim especially when other information is provided at the service line.
Because the guide fails to provide the specific business rules, we urge that the reference to NDC and the new 2410 Loop be removed from the institutional guide.
A request to remove all industry usage requirements for the reporting of physician information at the service line was made for data elements in Loops 2420A, 2420B, 2420C, and 2420D.
Currently institutional providers do not report physician or other caregiver information at the line item level. The rationale for removal is due to the enormous cost associated with having to comply with a set of requirements not necessary for claims adjudication even though the guide defines this as “situational usage”. Although some provider system software can capture this information at the time care is rendered to the patient, only a small percentage of these providers currently subscribe to this additional system feature from their service vendor (less than 6 percent). Moreover, virtually none of those who subscribe to this added system feature have the ability to interface this information with their billing record without costly redesign.
Currently, some state programs indicate they have a need and utilize Level III HCPCS to capture similar information. The Final Rule on Transaction Standards was very clear about the elimination of Level III HCPCS (local codes). It also suggested that when applicable, those Level III HCPCS codes should go through the HCPCS committees for possible assignment to a HCPCS Level I or Level II code. It did not condone substitution of Level III HCPCS for a new discrete data element.
Remove the loops that reference physician information at service line.
This item calls for the inclusion of the physician specialty on every institutional claim and is linked to the prior item # 128. Institutional claims do not need to have the physician specialty on each claim. The physician specialty assignments is an integral part of the National Provider Identification file and should be routinely captured in contracts that many health plans require providers to file.
This item should be removed from the institutional claim as claim adjudicators can obtain specialty through the National Provider Identifier or in their own health plan files.
There are still important issues that remain. For instance, the use of external codes as referenced in the implementation guides has caused some confusion as to their required use. The design of the NUBC’s data set is robust and relies on codification of many important health-reporting requirements. The reason for this approach is the dynamic nature of health care, especially with governmental programs like Medicare, which often rely on short notice for the establishment of new codes to meet congressional mandates.
The NUBC has prided it self as being able to meet many of these challenges without a major disruption to the Medicare program. The reason we were able to do so is in large part attributable to the UB’s code set that includes Value Codes, Condition Codes, Occurrence/Occurrence Span Codes and Revenue Codes. These specific code sets allows codification of new changes without a reconfiguration of the fundamental construct of the UB-92. Such a design adds stability to information systems that support the development of the UB-92. It also provides a return on the investment in billing information systems. Today the NUBC is proud that hospitals submit more than 98% of their Medicare claims electronically.
We would ask the NCVHS to expressly recommend adoption of these external code sets as contained in the UB data set for use within the institutional transaction set for billing. Again, these include: Value Codes, Condition Codes, Occurrence/Occurrence Span, and Revenue Codes. These code sets are referred to in the implementation guide, however there is some confusion among users as to whether they fall under HIPAA’s compliance mandate. We believe that they do.
Finally, the NUBC will soon ask the NCVHS to consider business rules around the use of the clinical code sets, as well as those around the UB data set. These rule we believe are important for “standardizing the standard” and making certain that the entire health care community understands their obligation to maintain and update changes made to these code sets. Today the NUBC is also embarking on an examination of the entire UB code set. In part this is due to the moratorium to changes to the UB-92 structure that is set to expire next year. In anticipation of the expiration, we conducted a national survey to learn of areas requiring change. We are also preparing for a possible expansion of the clinical codes to recognize the eventual adoption of the ICD-10-CM as well as ICD-10-PCS. In addition, we are looking at adding more information about the initial patient encounter.
Last year we tackled a persistent problem associated with many emergency room claims. We noticed that many emergency room claims required further follow-up because the final diagnosis on the claim may, upon initial review, appear out of line with the resources delivered to the patient. Upon investigation, we learned that many health plans have strict rules about in-plan care versus out-of-plan-care. With the enactment of the Balanced Budget Act ’97 it also included language about the “prudent layperson”. The prudent layperson concept in BBA allows an individual to determine whether they need to seek emergency room care without penalty. The problem is that the claim did not contain a full picture of the events that caused the emergency visit. After study, the NUBC added a new data element: “The Patient’s Reason for Visit Code”. This change further elaborates on the events that led to the emergency visit. As a result, many managed care companies have reduced their medical review backlog by 40% and have seen corresponding reductions in staff resources as well. For providers, this change has reduced the need for additional follow-up with medical record information and has improved provider’s cash flow. For patients, there is less administrative hassle associated with having to explain why it is they sought care outside of their health plan.
The NUBC plans for further enhancements to include possible expansion of external cause of injury codes as well as the physician’s initial diagnosis. We believe these will provide a more complete story for the claim and will further improve on administrative processing of claims by avoiding costly medical necessity reviews.
Although there are still unresolved issues that the DSMOs need to work through, the NUBC is willing to lend its support. The NUBC will continue to research some of the unresolved issues to offer workable solutions.
Again, thank you.