Data And Code Set Data And Code Set Data And Code Set Data And ...
SNIP -- Transactions Work Group
Business Issues Sub Work-Group
Data and Code Set
Da
Compliance
Compliance
A White-Paper Describing the Business Issues
and Recommended Short and Long Term
Solutions Associated With Data and Code Set
Compliance
Authors:
Liza Moran, BCBS of Massachusetts
Sandra
McCarver,
Highmark
DRAFT – As of 1/11/01
WEDI SNIP White Paper Disclaimer
This document is Copyright © 2001 by The Workgroup for Electronic Data Interchange. It may be
freely redistributed in its entirety provided that this copyright notice is not removed. It may not be
sold for profit or used in commercial documents without the written permission of the copyright
holder. This document is provided "as is" without any express or implied warranty.
While all information in this document is believed to be correct at the time of writing, this
document is for educational purposes only and does not purport to provide legal advice. If you
require legal advice, you should consult with an attorney. The information provided here is for
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The existence of a link or organizational reference in any of the following materials should not be
assumed as an endorsement by the Workgroup for Electronic Data Interchange (WEDI), or any of
the individual workgroups or sub-workgroups of the Strategic National Implementation Process
(SNIP).
The following draft document has been prepared by SNIP
(Strategic National Implementation Process) for the express
purpose of soliciting industry review and input. All
comments received by or before the comment closing date
will be considered for inclusion in the associated final
document.
SNIP recognizes the critical importance of Industry review
and input to the successful implementation of HIPAA. So
please take this opportunity to participate and let your voice
be heard.
DISCLAIMER
This [article] is Copyright© 2000 by The Workgroup for Electronic Data Interchange. It may be
freely redistributed in its entirety provided that this copyright notice is not removed. It may not
be sold for profit or used in commercial documents without the written permission of the
copyright holder. This article is provided "as is" without any express or implied warranty.
While all information in this Article is believed to be correct at the time of writing, this article is
for educational purposes only and does not purport to provide legal advice. If you require legal
advice, you should consult with an attorney.
2
Data and Code Set Compliance White-Paper
Purpose and Scope
Purpose
The Business Issues Sub Work-Group of the SNIP Transactions Work-Group has identified one or
more issues that will affect implementation of the data and code set provisions of the HIPAA
Transaction and Code Sets final rule. The purpose of this white paper is to document these issues
and to propose solutions that would apply to either the 24-month implementation window and/or the
post 24-month implementation period.
Scope
The scope of this white paper will address the following specific data and code set issues:
1. NDC Codes: Are there any best practice recommendations which might assist providers and
payers in accepting and utilizing NDC codes in billing, adjudication, payment, and other systems
as needed? What would the implementation approach be during the 24-month implementation
window, and after?
2. Elimination of Local Codes: What is the business impact of eliminating local procedure,
diagnosis, and other trading partner specific codes? How will providers and payers mitigate those
problems? How will we coordinate the petitioning of Data Standards Maintenance Organizations
(DSMO’s) to add high-volume local codes to national ANSI structures?
3. Non-Medical Code Sets: Codes which are not governed by DSMO’s may require mapping to enable
payers to utilize them for processing purposes. To what extent can these mappings be developed into a
best practice for greater consistency across the industry?
4. Version Control of Medical Code Sets: How will version control of data standards and HIPAA
implementation guides be managed? There may be some conflicts in interpreting the
requirements which may lead to confusion during implementation.
5. Claim Line Items: How will payers respond to the requirement to enable submissions by
institutional providers of claims with line items up to 999 and for professional and dental providers
of up to 50 line items? Are there associated best practices which can be recommended and / or
business issues which can be mitigated?
6. Preventative Health Services Reporting: Do the code sets support required tracking of
preventative health services measured by HEDIS? These services are not typically reported as a
claims expense, and are not directly supported by nationally recognized code sets.
DRAFT – FOR UPDATES OR QUESTIONS CONTACT LIZA MORAN 617-847-5722
1. Overview
HIPAA regulations and compliance thereof will require, for many in the health care industry, the replacement of
local codes currently in use, as well as techniques to map to/from or adapt to other standard codes. The evolution
of the industry away from payer- or provider-specific code values will not be achieved immediately, and will require
in some instances changes to contractual relationships, processing systems, and other business functions. The
purpose of this paper is to identify some of the business issues associated with code conventions which have
general relevance to the health care industry, review options available to address them, and make
recommendations accordingly.
2. Background
For ease of reference, background information for each sub-topic has been included within the recommendation
section.
3. Business Drivers
The reasons for writing this White Paper are:
• To provide the healthcare industry with an outline of issues required to address the code and data
requirements
• To provide a structure of consistency across the industry to reduce administrative costs of converting to ANSI
standard code structures
• To reinforce the importance of utilizing standard code values by offering recommendations to covered entities
developing solutions to address business drivers for local code use.
4. Recommendation for Solution
Subtopic 1: NDC Codes
Are there any best practice recommendations which might assist providers and payers in accepting and
utilizing NDC codes in billing, adjudication, payment, and other systems as needed? What would the
implementation approach be during the 24-month implementation window, and after?
Background:
NDC codes are greater in length than other code structures. They are used primarily by provider
clinical management systems and pharmacy payers. Payers and providers may not immediately
be able to process and store this information for billing and reimbursement purposes. There may
need to be an interim solution enabling the transmission, receipt and translation of these codes
during the 24 month implementation window.
Provider and payer issues with respect to NDC code usage for claims submission purposes may
be quite different. Provider issues may include the following:
a. The NDC code may be used today by hospitals within clinical systems, but are not passed to
billing systems for purposes of claims filing. This may require the development of interfaces
between these two systems to accommodate the submission of NDC code information on the
claim 837 record.
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b. NDC codes are updated with high frequency. Provider systems may not perform coding
updates for each release of new NDC codes. This may an issue held in common with payers.
c. Due to the complexities of the hospital pharmacy dispensing environment. The drug ordered
may not always be the same drug dispensed to the patient. The NDC code may need to be
frequently updated to reflect this circumstance. For example, if a particular brand of
acetominophen is requested, another may be dispensed and provided to the patient. This
poses immense complexity to hospital systems interfaces being developed to capture the
appropriate NDC code information for billing purposes.
d. The package amounts represented by current NDC Code structures are not equivalent to
dosage amounts normally ordered for and administered to a patient. Patients are not typically
in the hospital for lengthy periods of time and receive drugs on a daily basis rather than
weekly or monthly. This poses issues for both providers and payers attempting to correctly
represent and reimburse the drug service actually rendered since the dosage amounts in the
NDC codes are significantly larger than those actually dispensed.
Payer issues, in addition to those noted above, may include:
e. NDC codes are significantly longer than HCPCS and CPT. This poses challenges for
payment systems. If the procedure code field is not expanded, then the NDC code must be
mapped internally for processing purposes. The payer must then either map again for
remittance, or must retrieve the original NDC code from a stored version of the incoming
record.
f. NDC codes describe drug packaging and units by manufacturer, which can be useful to
payers in determining claim reimbursement. However dosage information is reported as
service units, as described above in item e, which are not always equivalent. This poses
some concern for payers in ensuring that the reported claim information is correctly
interpreted.
Alternatives:
Payers and providers are required to accept and/or transmit transactions and code sets in compliant
format. They may then handle them in the following manner:
1. For payers, NDC codes can be mapped to internal system codes. This may involve storage of
incoming procedure code values prior to mapping of data values. For purposes of generating the
remittance, the payer would retrieve the submitted NDC code rather than remapping the internal code.
For providers, internal drug code values can be mapped by a clearinghouse to standard format This
option assumes providers have developed a solution to address the development of any new interface
between clinical and billing systems.
2. Convert internal processing systems to accept these values without a data mapping. For providers,
interfaces which accommodate NDC reporting would be required between clinical and billing systems.
3. A proposal has also been made to provide a standard mapping from NDC to a five-digit procedure
code, consistent with HCPCS or CPT code value length. This could be achieved by payers / provider
replicating the logic necessary to perform the mapping (internal 5 digits representing the drug type) or
by a central entity. Since this is a dynamic code structure, maintenance and distribution of this
database would be a large-scope effort.
Short-term Recommendation: Options 1 or 2 above are recommended to achieve compliance. In view of
the fact that most payers do not currently utilize NDC codes (many use the HCPCS J codes), it is likely that
Option 1 will be the most frequent solution during the 24 month implementation window. It is assumed that
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the data supplied on the incoming claim record will be stored for return on response records for use on the
remittance. Option 3 does not help achieve compliance with the law, nor is it clear how this data would be
maintained. It is counter-productive to suggest that payers should maintain their own mapping, since this
will increase processing cost, and make payers vulnerable to future changes in NDC code structure.
Long-term Recommendation: In order for the health care industry to achieve full value of standard code
values, and to take advantage of the detail captured within the NDC code structure, it is recommended that
Option 2 become the long-range strategy. It is further recommended that the responsibility to address the
long-range recommendation for NDC code requirements be referred to the WEDi SNIP HIPAA Success
Project.
Subtopic 2: Elimination of Local Codes
What is the business impact of eliminating local procedure, diagnosis, modifier, and other trading partner
specific codes? How will providers and payers mitigate those problems? How will we coordinate the
petitioning of Data Standards Management Organizations (DSMO’s) to add high-volume local codes to
national ANSI structures?
Background:
Each covered entity will experience transition challenges as they move toward the national coding
standards and away from trading partner specific editing. Some of these issues are extremely
local in nature, others may be shared by many or all parties. During the 24-month implementation
window, trading partners will need to work together to eliminate local and proprietary code usage.
Specific issues of general interest may include:
a. Anesthesia services are often denoted by use of HCPCS or local modifiers with surgical
procedure code, and are uniquely reported as units of time. CPT offers codes beginning with “00”;
however, these may not be sufficient for processing purposes. They are global in nature, and
most payers only will reimburse anesthesia for covered surgical services. With the elimination of
local modifiers, alternative techniques are required to enable payers to differentiate these services
for pricing, duplicate detection and medical policy purposes. These might include holding
matching anesthesia claims with associated surgical services in order to perform payment
determination.
b. Certain services have code values in multiple coding structures. For purposes of this paper, these
will be referred to as “overlap codes”. For example, some dental codes are included in both CDT
and CPT-4; some drug codes are available in both HCPCS and NDC. Payers may use the code
type to determine line of business. Others may only recognize code structures for products they
support. For example, if a payer does not support dental or pharmacy processing, they may not
currently utilize CDT or NDC code structures. Covered entities which are required to implement
unfamiliar code sets may have a need to modify the implementation schedule to allow time for
transition to new values. DSMO’s will need to reach agreement on which code structure takes the
lead on specific overlap codes e.g. CDT handles all dental codes, etc.
c. Local codes are often used to support specific processing purposes e.g. pricing, coordination of
benefits with Medicaid, Medicare, and other carriers. Alternatives must be identified, or some
codes must be added to national standards in a timely manner.
For example, Medicaid, as payer of last resort, reimburses many services not typically covered by
health plans. It may be required, however, that these services be formally rejected by the
primary payer in order to be eligible for reimbursement by Medicaid.
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Likewise, Medicare may identify (and HCPCS currently supports) certain services covered by
some intermediaries through use of local codes. These codes may identify services
which are uniquely coordinated in some way with the secondary payer.
d. Some service types aren’t fully addressed by any of the mandated codesets. For example, there
are insufficient standard codes for vision services. If all J codes are eliminated, certain DME items
cannot be accurately reported. These codes should be regulated by one of the DSMO’s in order
to enable the industry to fully maximize efficiency of standards code values and avoid downstream
manual intervention.
e. Some services defined by national codesets are not currently covered by HIPAA requirements.
For example, Home Infusion Therapy providers… Section 162.1002 of the implementation guide
sets forth the standard code sets, with additional comment clarifying the usage of other national
code structures as follows:
“Comment: Although there was wide support for the code sets that were proposed, a number of
commenters pointed out that additional code sets were needed to cover some health services
recorded in administrative health transactions. One commenter mentioned that the code sets
proposed as standards lacked coverage of alternative health care procedures and
recommended that the Alternative Link coding system also be designated as a standard code
set. Commenters also indicated that none of the proposed standard code sets covered home
infusion procedures; they recommended that the Home Infusion EDI Coalition Coding System
(HIEC) be selected as a HIPAA standard. HIEC is currently used by some non-governmental
health plans. One commenter recommended that dental diagnostic codes (SNODENT)
developed by the ADA be used as a national standard. This commenter stated that the ICD-9-
CM codes were inadequate for dentistry.
“Response: No single code set in use today meets all of the business requirements related to the
full range of health care services and conditions. Adopting multiple standards is a way to
address code set inadequacies, but can also introduce complexities due to code set overlaps.
We acknowledge that the coding systems proposed as initial standards may not address all
business needs, especially in the areas of alternative health care procedures, home infusion
procedures, and dental diagnoses. Specific shortcomings should be brought to the attention
of the code set maintainers. The adoption of additional standards may be an appropriate way
to fill gaps in coding coverage in these areas. Additional code sets must be analyzed by the
DSMOs that will make recommendations to the National Committee on Vital and Health
Statistics. In order to request changes, we recommend working through the processes
described in §§162.910 and 162.940. In the interim, segments exist in the standard
transactions which allow for manual processing of services for which codes have not been
adopted.”
A process for collectively working with the NCVHS and DSMO’s is recommended. This will help
ensure all providers have a national code structure with which to bill, and all payers have an
opportunity to implement these code structures in time to meet implementation deadline.
f. Elimination of payer- and provider-specific local codes may cause delays in processing as payers
seek alternative methods of applying edits, unique pricing, and other adjudication logic.
Workarounds may rely on manual procedures. Use of Not Otherwise Classified (NOC) codes may
increase in response. This may force some types of claim submissions to paper. Covered entities
will need to plan carefully to maximize benefits of electronic data interchange, and to reduce
manual processing. Local code issues will need to be prioritized. The simpler solutions would be
implemented first and the more complex solutions planned as closely as possible for
implementation in accordance with industry best practices.
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Alternatives: Although each covered entity will have different issues in conversion to full and exclusive use
of national code values, there are some common approaches which may be recommended. These may
include:
1. Detailed analysis of local code use by trading partner and/or business driver. These issues can then
be sorted into categories of complexity. Simple and/or maintenance corrections can be addressed
immediately. More complex issues require in-depth planning and longer implementation timelines.
2. Legitimate, generally accepted procedures which lack a national code will require a petition for addition
to the code structure. In most cases, the authority of each DSMO is clear. Where it is less clear, work
to identify situations and make recommendations to address.
Short-term Recommendation: Payers will be able to meet implementation readiness dates for most trading
partners through mapping of local codes to standard code values. In order to achieve full compliance for all
partners, it is recommended that an analysis of common code issues be completed by an industry effort,
perhaps by a WEDi SNIP Subgroup. It is further recommended that a single petition be made to standards
bodies to address these issues. It is possible, but not likely, that these issues will have been fully identified
by initial test readiness date; therefore, it is recognized that some outlier codes will require longer
implementation timeframes i.e. beyond 10/1/01 payer readiness date. This may disproportionately affect
the readiness of certain provider types who are less well-supported by current national code structures.
Long-term Recommendation: A process to identify, get consensus on, and expedite the introduction of
additions to the code standards is needed. This has been recognized by the DHHS. Ultimately, more
frequent changes to the issuance of code updates may be needed in response to the dynamic health care
environment. Emerging fields such as alternative health care, genetic therapy, and other non-traditional
methods of treatment must also be assigned to a standards body for regulation.
Subtopic 3: Non-Medical Code Sets
Codes which are not governed by DSMO’s may require mapping to enable payers to utilize them for processing
purposes. To what extent can these mappings be developed into a best practice for greater consistency across
the industry?
Background:
a. Taxonomy codes are not in common use today to identify provider attributes. Will some of these values be
replaced by the NPI database? What body regulates the taxonomy code structure? Should there be
general agreement for initial implementation that providers and payers will map to high-level codes e.g.
psychiatry rather than adolescent psychiatry? Until the implementation guide for provider identifier is
finalized, covered entities should strive to meet the minimum taxonomy code requirements.
b. Translation of adjudication reasons on the 835 remittance to standard values may limit provider
understanding of claims adjudication issues. This could prompt additional calls for assistance to
determine reason for claims action. As a result, providers may bill member for services in error.
Trading partners will need to reach agreement on how best to communicate additional information
relative to claim status. There may be a value to enhancing this field in after the 24 month
implementation window.
Alternatives: As with procedure and diagnosis code sets, there is a need to identify and promulgate the use
of national values for other information values. Identifier fields must be populated with alternative values
until the final rule has been published. For some code values, additional detail may need to be specified in
future releases, either the addition of new values or clarification of current version. However, for many of
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these codes there is no national guideline currently in place. It would be beneficial to develop a “best
practice” to assist providers and payers in this area.
Short-term Recommendation: Develop “best practices” for code values not regulated by DSMO’s. This
would include general agreement on how to populate identifier fields until requirements have been
finalized. As common usage is identified, or additional values of wide benefit to the industry are
documented, it is recommended that a process be developed to review and approve them for
incorporation into the implementation guides.
Long-term Recommendation: Identify and/or appoint a DSMO to maintain ownership of and manage the
process of updates to these code sets.
Subtopic 4: Version Control of Medical Code Sets
How will version control of data standards and HIPAA implementation guides be managed? There may be
some conflicts in interpreting the requirements which may lead to confusion during implementation.
Background:
The preamble of the implementation guide specifies that the claim be filed with the medical code structure
in effect at the time services were rendered, while other code sets are required to follow the
standard in effect at the time the transaction is generated. On page 50370, 162.1000 General
Requirements: The rule says to use the codes described in 162.1002 that are valid at the time the
healthcare was furnished. However, 162.1002 does not contain all the codes that are valid prior to
10/16/2002. Therefore, a conflict exists if a claim for a service rendered prior to 10/16/2002 and
involving a J code, local code, etc, is submitted after 10/16/2002. To use the code valid at the
time of service, we should use the J code or local code. In addition, the following issues may be
experienced:
a. Requires all payers, providers and clearinghouses manage multiple versions of medical code sets,
which are accessed via service date. This may pose data storage problems due to differences in
timely filing requirements. Standards for data retention may differ.
b. Will all code upgrades be performed on a consistent, regular basis? CPT-4, HCPCS and ICD-9 are
currently released annually on a scheduled basis. However, this may not be the case for other
code sets, such as CDT and NDC. According to the Federal Register Page 50329: “Daily updates
to the New and Generic Prescription Drug....weekly updates to the FDA Drug Approved
List.........NDC Directory is updated on a quarterly basis...”. Covered entities may need additional
clarity regarding the frequency of updates to the NDC repository.
Alternatives: Current policy incorporated within the implementation guides indicates that code sets will be
updated consistent with current practice. Providers and payers will be required to maintain multiple
versions of these files. These updates are not currently synchronized with a regular HIPAA standards
update. For the immediate implementation timeframe, providers and payers will need to address short
term data storage and other associated business issues. Long range, it may make sense to develop more
stringent version control standards.
During initial implementation, all covered entities must utilize the mandated code set for services which
occurred prior to implementation of the standards. In situations where the code has been deleted from the
implementation mandated standard, but was in effect at the time of services, there are at least two possible
alternatives to handle:
1. Develop a best practice that allows all eligible processing to occur with deleted code
2. Allow this to become part of trading partner agreements.
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Short-term Recommendation: During the immediate 24 month implementation phase, it is recommended
that providers and payers test using current standard data, and work to minimize the impact of deleted
codes, etc. This will enable both parties to implement using the standard version of the code sets, while still
providing an alternative for submitting claims for prior periods which may be subject to other national or
local pre-HIPAA processing requirements. Exceptions which extend beyond the 24 month window should
be handled via trading partner agreement
The following chart is intended to outline the requirement for submission at the time of transition to full
HIPAA compliance, as outlined in the Implementation Guide Page 50370, Subpart J, Letter a:
HIPAA Code Set Transmission Guidelines
If claim type … and record is
…then claims must
… for applicable
Code
is…
transmitted to payer …
be in….
code sets…1
Sets
Institutional
Prior to 12:00 AM 10/16/02 Formats agreed to
Code Set in effect at
between parties
time of service
including local codes
On or after 12:00 AM
X12N format
Standard Code Set in UB92
10/16/02
effect at time of
service
HCPCS
ICD-9
Professional
Prior to 12:00 AM 10/16/02 Formats agreed to
Code Set in effect at
between parties
time of service
including local codes
On or after 12:00 AM
X12N format
Standard Code Set in CPT-4
10/16/02
effect at time of
service2
HCPCS
ICD-9
Dental
Prior to 12:00 AM 10/16/02 Formats agreed to
Code Set in effect at
between parties
time of service
including local codes
On or after 12:00 AM
X12N format
Standard Code Set in CDT-3
10/16/02
effect at time of
service
Long-term Recommendation: Overall, providers and payers would benefit from close coordination of code
sets and standards implementation efforts. One alternative may be to implement all transaction and code
set changes at once on regular basis. Any recommendation in this regard would need to consider the need
to remain responsive to a fast paced health care services environment, while at the same time minimizing
the implementation impact to covered entities. We would further recommend that all organizations that
maintain medical code sets (AMA, HCFA, ADA, etc) adopt a standardized minimum of 120 days between
the final publication of a given medical code set update and the effective date for the change in medical
1 Actual dates to be inserted for relevant codesets
2 Note that there may remain some issues with “J” codes, NDC codes and local codes which may force exception
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code sets. Currently there are differing timeframes between publication and effective dates specific to
each of the medical code set maintenance organization. The standardization of timeframes between
medical code set updates and effective dates will allow all stakeholders that utilize the medical code sets to
update and test any processes and or information systems that would be impacted by the medical code
set updates. This would help minimize the impact of changes to a given process or system.
Standardization would also benefit the industry by incorporating time to develop and implement effective
provider education on any medical code set changes.
Subtopic 5: Claim Line Items
How will payers respond to the requirement to enable submissions by institutional providers of claims with
line items up to 999 and for professional and dental providers of up to 50 line items? Are there associated
best practices which can be recommended and / or business issues which can be mitigated?
Background:
Providers are currently required to submit services in unbundled format for Medicare filing. In order to
accommodate this requirement, Medicare is expanding internal system limit to 450 lines. Payers
who coordinate services with Medicare may already be receiving claims with line totals exceeding
the capability of their processing systems. They may have responded with manual workflow
changes, or in some cases may have made some system accommodation. Due to low claim
volumes, it is assumed that this has been an insufficient business driver to date to cause payers to
engage in major system change in support of this requirement. To support the HIPAA
requirements, payers will need to reevaluate their approach.
Alternatives: Payers may take a variety of approaches to address this issue, in some part driven by the
type of business they support. For example, a dental carrier may project fewer large line-item claims than a
medical carrier processing institutional and professional claims. Options may include:
1. Expand system capability to accept the maximum number of lines contained within HIPAA
transaction record
2. Expand system capability to increase line item processing capability. Determine threshold using
some internal business and/or technical driver. Claims exceeding this limitation handled manually.
3. Accept transactions; dump claims to paper and key manually in increments acceptable to internal
system. Match up claim files with incoming 837 data to produce 835. Will probably require holding
all claim lines until all incremental claims have processed.
4. Accept transactions. Automate the “splitting” of claims data into increments acceptable to internal
system. Match up data in automated fashion with incoming 837 data to produce 835. Use “line”
item feature on 837 record to report back to provider which services were paid.
Short-Term Recommendation: All above options are feasible and should enable payers to meet basic
compliance requirements if correctly implemented. However, Option 4 seems to provide the most realistic
solution for the majority of payers, and the one best suited to provider’s needs. Options 1 and 2, given the
24 month implementation requirement, are probably not feasible for most payers. They would require
either a major-scope system change, or a change of systems. It is assumed that these are not options that
most payers have selected at this time. Option 3, being a largely manual option, is not likely to be selected
either. It will not assist payers to meet their automation goals, and will cause unacceptable processing
delays in provider payments. Option 4 does require some system effort, but will enable most processing to
occur in automated fashion, and does provide a mechanism by which providers can track the payment of
service lines. There may be some unavoidable service issues associated with differences in processing
time for the different claim “splits”.
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Long-Term Recommendations: Ultimately, Option 1 may be the best approach for most payers and
providers. As we move forward together in realizing the benefits of common electronic data interchange,
payers will seek long-range system solutions which help them achieve the maximum savings and the best
service. System vendors will respond with solutions which enable the community to meet their HIPAA
requirements. The timeline will vary for each payer, but the goal should be for all to fully meet the
requirement in the future.
Subtopic 6: Preventative Health Services Reporting
Do the code sets support required tracking of preventative health services measured by HEDIS? These
services are not typically reported as claims expense, and are not directly supported by nationally
recognized code sets.
Background:
For managed care health plans, HEDIS reporting requirements include the tracking of preventative and
other health services for managed care members, regardless of where, when or by whom the
service was rendered. For example, when a new female member joins an HMO health plan, the
payer is required to gather – and the provider is required to gather data on pap smear and
mammography examinations and outcomes. These services are likely to have been rendered by
different providers, at a time prior to the member enrolling in the health plan. New CPT codes
called performance measurement codes have been proposed to address this issue. These are
not part of current HIPAA code set requirements. In order to support HEDIS quality reporting
requirements, the industry needs a coding technique to capture and report these services.
Alternatives: Health plans subject to HEDIS reporting requirements may need to explore methods of
collecting health status data outside of the claims process. Current techniques to report on this data may
require local modification to ensure consistence with HIPAA data requirements. However, since there is no
national guideline currently in place, it would be beneficial to develop a “best practice” to assist providers
and payers in this area.
Short-Term Recommendation: The AMA plans to release these new performance measurement tracking
codes by early 2002. Local reporting approaches may need to continue until these have been introduced.
Long-Term Recommendation: May not be necessary if addressed as planned through CPT code
structure.
Value Proposition
The value in accepting these recommendations will be to provide guidance to business partners during the
implementation of transactions and code sets, while also setting the framework to address anticipated
future needs. It is also expected that ongoing dialogue on data and code set issues will facilitate the
development of effective solutions through future releases, enhancing and expediting industry readiness.
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Document Outline
