My name is Bob Owens. I am the associate executive director of information technology/CIO for the American Dental Association. (ADA). It is my pleasure to appear today on behalf of the ADA before the Subcommittee on Health Data Needs, Standards, and Security of the National Committee on Vital and Health Statistics (NCVHS). We would like to thank you for the opportunity to testify. This statement summarizes the views and concerns of the ADA in response to the questions you provided on the codes and vocabularies to be used by the dental profession. The ADA would like to again emphasize its shared commitment to advancing standardization and administrative simplification. The following points summarize our statement and recommendations for achieving the goals intended by administrative simplification:
1. Can one system serve most if not all purposes i.e. surveillance, quality assessment/improvement, clinical research, billing/management? If not, which systems can serve most of these functions?
The ADA recommends that administrative simplification regulations not reach beyond their core focus of administrative and financial transactions. The information sent on dental claims currently does not provide researchers with the ability to study treatment patterns and the outcomes of care. Only the service(s) provided to the patient and not the condition(s) being treated are reported on a dental claim. While the ADA believes that a comprehensive clinical coding system is essential for the computer-based patient record (CPR) , we do not believe that CPR coding issues should drive the code standards for the administrative transactions. Therefore, the ADA recommends that the codes contained in Current Dental Terminology (CDT), Current Procedural Terminology (CPT), HCFA's Common Procedure Coding System (HCPCS), and the International Classification of Diseases continue to be used as the standards for dentistry under HIPAA.
2. Is it administratively simpler to use the same disease classification for administrative transactions and for statistical reporting?
There may be some economies gained from the use of a single coding structure. However, they would quickly diminish if the additional information requirements go much beyond what they are today.
3. What codes and classifications do you use in administrative transaction now? What do you perceive as the main strengths and weaknesses of current methods for coding and classification of encounter and/or enrollment data?
Dentistry currently uses the codes contained in CDT developed by the ADA, CPT developed by the American Medical Association, HCPCS and the International Classification of Diseases version 9 (ICD-9 CM). The codes developed by the ADA have been developed under a joint effort by dental professionals and the insurance industry and are widely accepted as the standard for reporting dental treatment. The Association is also in the final stages of a process to develop a diagnostic coding system to attribute a diagnosis to the service(s) rendered. This will also enable more thorough outcomes research.
4. What codes and classifications do you recommend as initial standards for administrative transactions, given the time frames in the HIPAA? What specific suggestions would you like to see implemented regarding coding and classification?
The ADA recommends the use of its CDT coding system, CPT, HCPCS, and ICD-9-CM for all dental claims. As mentioned earlier, the diagnostic coding systems currently in development have not reached the necessary level of industry acceptance to make them viable candidates for administrative transactions at this time. The ADA recommends that the Secretary of DHHS move forward with the adoption of current coding systems for the specified transactions in the law. However, adoption of coding standards for clinical transactions should be deferred until the appropriate frameworks, data dictionaries, cross mappings and harmonization of the current and proposed standards can be fully developed.
5. Prior to the passage of HIPAA, NCVHS developed a clinical modification of ICD-10 (ICD-10-CM) and HCFA developed a new procedure coding system for inpatient procedures (called ICD-10-PCS), with a plan to implement them simultaneously in the year 2000. On the pre-HIPAA schedule, they will be released to the field for evaluation and testing this year. If some version of ICD is to be used for administrative transactions do you think it should be ICD-9-CM or ICD-10-CM and ICD-10-PCS, assuming that field evaluations are generally positive?
The Association believes that, in addition to the previously mentioned CDT, CPT and HCPCS coding systems, ICD-9-CM should continue to be utilized for administrative transactions with migration towards the upgrade of ICD-10-CM and ICD-10-PCS as they become viable. This assumes continued use of CDT and CPT and their respective successors.
6. To what extent do you feel that your discipline and practice setting are well represented by current systems for coding health conditions, diagnoses, services and procedures in administrative and financial transactions?
The ADA's CDT coding standard has a long successful history of providing the information resources necessary to facilitate dental administrative transactions. This system is utilized by more than 146,000 dentists or over 72% of the total profession.
7. Recognizing that the goal of P.L. 104-91 is administrative simplification, how, from your perspective, would you deal with the current coding environment to improve simplification, reduce administrative burden, but also obtain medically meaningful information?
Given the current state of the industry and the timeline to implement the new regulations, the ADA recommends that DHHS adopt the CDT, ICD, CPT and HCPCS coding systems for the initial HIPAA regulations. The current coding systems do allow for basic clinical analysis to occur. In addition, DHHS should work with the HIPAA consulting organizations to maintain a balanced level of diagnosis and procedural codes in future updates of the HIPAA regulations.
8. What issues do you encounter linking data coded with different classification systems and trying to crosswalk between (or among) classification systems?
This is not an issue for dentistry given that the CDT is the only nationally recognized procedure coding system used in the dental profession. Also, the diagnostic coding system being developed by the Association for dentistry has incorporated the appropriate ICD-9 codes into the system, thereby eliminating any problems with crossover to other related systems.
9. What are the impact on and implications for current (and emerging) classification systems as we migrate towards computer-based patient records (cpr)? To what extent can the major classification systems currently in use serve, in part, as vocabulary for the cpr, and if another system is recommended as the vocabulary for cpr, how can we assure that it crosswalks relatively easily to the classification systems currently used in administrative and financial transactions?
The current CDT codes alone are not sufficient to maintain a complete dental clinical record by themselves. Recognizing the need for standards in clinical terminology and the limitations of the current coding systems, the ADA engaged in the difficult task of creating a clinical terminology and coding system that will provide the profession with comprehensiveness and varying degrees of utility. We are currently developing a microglossary of the Systematized Nomenclature of Medicine (SNOMED) so that patient history, findings, services and outcomes can be represented accurately. In addition, we are developing a comprehensive glossary of the dental terms. Standardized terminology must have explicit definitions. A collective guide is important for consistent interpretation of terms by the profession and aggregate data analysts. This work is being paced accordingly with the other agencies of the ADA involved in the development of standards for the Computer-based Oral Health Record and the Computer-based Patient Record.
10. How might the NCVHS work with the Department to assure that the USA coordinates development of an international medical dictionary, classification/coding system, etc., including the terms, a process to keep continuously such terminology updated, and a server to deliver the content to whoever needs access.
To assure that the USA coordinates development of an international medical dictionary and coding systems, NCVHS should consider working with the HIPAA consulting organizations.
11. What are the arguments for having such systems in the public domain vs within the propriety sector? (How might we best deal with existing private sector systems if public domain is the way to go?)
To be effective, a coding standard must have an experienced organization maintain the system in question. However it is important to make the coding systems readily available to the general public. When a standard is maintained in the public domain, there tends to be quality control issues.
12. Is it practical to move to a single procedure classification on the timetable required for initial implementation of administrative standards?
Not for dentistry. While the codes in CDT are the only nationally recognized coding system for dental claims, dentists also report treatments using CPT, HCPCS and ICD-9 codes.
13. A Coding and Classification Implementation Team have been established within the Department of Health and Human Services to address the requirements of P.L. 104-191; the Team's charge is enclosed. Does your organization have any concerns about the process being undertaken by the Department to carry out the requirements of the law in regard to coding and classification issues? If so, what are those concerns and what suggestions do you have for improvements?
The ADA is concerned that if the DHHS attempts to address the coding systems required for health records in this initial regulation, the administrative simplification intended by HIPAA will be compromised. Therefore the ADA recommends that DHHS use the existing, proven administrative coding systems mentioned, the CDT, CPT, HCPCS and ICD-9 for all dental administrative transactions.
Thank you for the opportunity to present our perspectives on issues associated with administrative simplification. The ADA looks forward to a continued and productive relationship with the NCVHS and the Subcommittee on Health Data Needs, Standards, and Security.