National Committee on Vital Health Statistics
Presented by:
Nelly Leon-Chisen, RHIA
Director, Coding and Classification
American Hospital Association
Chicago, IL 60606
I am Nelly Leon-Chisen, the American Hospital Association’s (AHA) director of coding and classification. On behalf of our nearly 5,000 member hospitals, health systems, networks, and other providers of care, I would like to thank you for the opportunity to provide comments on the gaps in the current Health Insurance Portability and Accountability Act (HIPAA) medical code sets.
The AHA has worked with the Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) to ensure appropriate interpretation and application of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Collectively, with the addition of the American Health Information Management Association, these agencies and associations are known as the “Cooperating Parties.” The AHA has also worked with HHS and the American Medical Association (AMA) to ensure that the same level of integrity and quality is achieved in the hospital application of Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS).
Standardization of clinical codes is extremely important to our members, particularly as they relate to the transaction standards identified in HIPAA. Hospitals and health systems are opposed to diverse reporting requirements for each of the clinical codes (mental health, alternative medicine and home infusion) being considered by the committee because they are costly and burdensome. In addition, wide variations in the use of the clinical code sets compromise the primary purpose of clinical code reporting -- to provide an accurate record of the patient encounter.
At the present time, we see no gaps in current HIPAA code sets that could not be addressed by first approaching those responsible for maintaining the designated code sets – ICD-9-CM, CPT and HCPCS.
We strongly support the current coordination and maintenance process for ICD-9-CM diagnostic and procedure codes. ICD-9-CM has a well-defined and effective maintenance and implementation process. The process is open, broad-based, and strives to take into consideration the needs of all users. The maintenance process takes into account the capabilities of the users to adapt to coding changes when they occur. Committee meetings are routinely scheduled and open to the public. Proposed changes are well publicized and an annual date certain for adopting the approved coding changes.
The AHA is encouraged by the recent efforts of the AMA’s CPT Editorial Panel to address the needs of our members and to consider the interests of other non-physician stakeholders.
The AHA, however, is very concerned about the lack of institutional provider input into the HCPCS level II update process. While proposed changes are posted on the CMS Web site and public comments are accepted, this is not the same as having provider representatives involved in the development and review process. Recently, public meetings have been held for the discussion of proposed durable medical equipment (DME) HCPCS codes. However, there is no comparable process for the remainder of the HCPCS codes.
The code development process for all codes should be:
Overall, the maintenance and implementation process should also be predictable and must take into account the capabilities of different users in adapting to coding changes when they occur. Providers should be able to rely on routinely scheduled meetings in order to review coding changes and to identify the implementation date for when approved coding changes take effect. Our members tell us that ideally coding changes should occur no more frequently than once a year. Providers should be able to utilize the same code set version over this given period, the use of this version must follow a consistent implementation date across all users, including payers.
Those responsible for maintaining codes should make their procedures for requesting codes available to the public so that users not currently familiar with the process may easily maneuver their way through the code proposal process. Code maintainers should be acutely aware of the need to also have a broad-based process that is receptive to the needs of all users—not just their traditional users. For example, CPT, long-considered by many to be originally designed for physician use only, is now a reporting system that must take into account the needs of non-physician providers especially when making decisions regarding new code proposals. The CPT Editorial Panel’s decisions on codes should not be based only on “how much physician work is involved” with a particular code but rather on whether there are sound business needs or other data collection and reporting requirement needs when it comes to approve a proposal.
The subcommittee has specifically requested input regarding alternative medicine, home infusion procedures, and mental health coding. I will now address each of these areas individually.
Our members currently use ICD-9-CM to report mental health diagnoses and conditions. The Diagnostic and Statistical Manual (DSM) is used primarily by psychiatrists as a diagnostic tool for assessments. During the revision process of DSM-III to DSM-IV, an attempt was made to minimize incompatibilities between DSM-IV and ICD-9-CM. In recent years, several proposals approved by the ICD-9-CM Coordination and Maintenance Committee now make ICD-9-CM more compatible with DSM. In addition, there is a crosswalk between ICD-9-CM and DSM-IV available, as well as published guidelines for using the crosswalk. We believe that ICD-9-CM currently meets the needs of hospitals and health systems for reporting mental health diagnoses and conditions.
Congress established the National Center for Complementary and Alternative Medicine (NCCAM) as part of the National Institutes of Health (NIH) in 1998. According to information provided on NCCAM’s website, complementary and alternative medicine (CAM) is generally defined as “those treatments and health care practices not taught widely in medical schools, not generally used in hospitals, and not usually reimbursed by medical insurance companies.” Approximately 15 percent of community hospitals in the United States provide complementary and alternative medicine services. When they do provide such services, however, the consumer generally pays for them. As such, the HIPAA electronic transaction standards would not apply to this type of services, since an electronic claim is not submitted to a health plan.
However, we are sympathetic to the need of providers who may need a method to codify and classify alternative medicine services for other, non-reimbursement related needs such as research, benchmarking, public health tracking, etc. In addition, as therapies currently considered complementary medicine are more widely adopted or covered by traditional insurance, there could be a need to report these services by hospitals and other providers. Therefore, we strongly urge providers of complementary and alternative medicine services to develop and present code proposals to the existing HIPAA medical code set standards maintainers. We oppose alternative coding systems that are proprietary or copyrighted, which would add to the already significant expenses incurred by providers to submit claims. In many instances, these coding systems also do not follow traditional (mainstream) coding conventions since many of these codes represent “bundled or packaged” sets of services. These codes may represent not only the service provided but also the provider type, or the type of insurance coverage.
Some of our hospital and health systems provide home infusion procedures through their home care services. They have not reported a gap in the current HIPAA code sets. We have been encouraged that a substantial number of new home infusion codes have been implemented in CPT-4 and HCPCS for 2002. If additional gaps in home infusion procedures are identified in the future, we support the addition of these services into existing HIPAA medical data code sets.
Again, thank you for the opportunity to present comments today. I will be happy to answer any questions you may have.