Consolidated Health Informatics

Standards Adoption Recommendation

Billing/Financial

**[Index]{.underline}**

1.  **Part I -- Sub-team & Domain Scope Identification** -- basic
    information defining the team and the scope of its investigation.

2.  **Part II -- Standards Adoption Recommendation** -- team-based
    advice on standard(s) to adopt.

3.  **Part III -- Adoption & Deployment Information** -- supporting
    information gathered to assist with deployment of the standard (may
    be partial).

####### Summary

Domain: Billing / Financial

**Standards Adoption Recommendation:**

HIPAA Transactions and Code Sets

SCOPE

The Billing/Financial standards are used to implement electronic
exchange of health related information needed to perform
billing/administrative functions in the Federal health care enterprise.
It is assumed that the HIPAA transaction and code sets will serve as the
basis for these standards.

**RECOMMENDATION**

The HIPAA approved transactions and codes set, both those currently
approved as well as future updates, are recommended for adoption.

## **OWNERSHIP**

Maintenance and control for the HIPAA approved codes sets are as
follows:

NCHS maintains ICD-9-CM

FDA maintains NDC codes

CMS maintains HCPCS codes

AMA owns and maintains CPT-4^®^ codes

ADA owns and maintains CDT^®^ codes

Alternative Link owns and maintains ABC codes as well as the pilot
participant registration logs

CMS maintains DRG codes

##### APPROVALS AND ACCREDITATIONS

# Public Law 104-191, the Health Insurance Portability and Accountability Act of 1996 mandates the use of HIPAA code sets. Each agency/organization that owns or maintains a HIPAA approved transaction or code set has established their own approval/accreditation process for their standards. Only the ADA is an ANSI approved SDO with the CDT^®^ being ANSI/ISO approved.

# ACQUISITION AND COST

See <http://cms.hhs.gov/hipaa/hipaa2/education/infoserie/4-tcs.doc> for
details on acquisition and accompanying information.

####### Part I -- Team & Domain Scope Identification

**[Target Vocabulary Domain]{.underline}**

+-----------------------------------------------------------------------+
| Common name used to describe the clinical/medical domain or messaging |
| standard requirement that has been examined.                          |
|                                                                       |
| ## Billing/Financial                                                  |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| Describe the specific purpose/primary use of this standard in the     |
| federal health care sector (100 words or less)                        |
|                                                                       |
| The Billing/Financial standards are used to implement electronic      |
| exchange of health related information needed to perform              |
| billing/administrative functions in the Federal health care           |
| enterprise. It is assumed that the HIPAA transaction and code sets    |
| will serve as the basis for these standards.                          |
+-----------------------------------------------------------------------+

**[Sub-domains]{.underline}** *Identify/dissect the domain into
sub-domains, if any. For each, indicate if standards recommendations are
or are not included in the scope of this recommendation.*

+--------------------------------------------------+-------------------+
| Domain/Sub-domain                                | In-Scope (Y/N)    |
+--------------------------------------------------+-------------------+
| Claim Submission for reimbursement               | Y                 |
+--------------------------------------------------+-------------------+
| Health Care Claim Payment/Advice                 | Y                 |
+--------------------------------------------------+-------------------+
| Eligibility Determination                        | Y                 |
+--------------------------------------------------+-------------------+
| ##### Prior Authorization and Referral           | Y                 |
+--------------------------------------------------+-------------------+
| Enrollment/Disenrollment                         | Y                 |
+--------------------------------------------------+-------------------+
| Coordination of Benefits                         | Y                 |
+--------------------------------------------------+-------------------+
| Claims Status Inquiry                            | Y                 |
+--------------------------------------------------+-------------------+
| Appeals                                          | Y                 |
+--------------------------------------------------+-------------------+
| Certificate of Medical Necessity                 | Y                 |
+--------------------------------------------------+-------------------+
| Claims Attachments                               | N                 |
+--------------------------------------------------+-------------------+
| Report of Injury                                 | N                 |
+--------------------------------------------------+-------------------+
| Non-Claim Payment Electronic Funds Transfer      | N                 |
+--------------------------------------------------+-------------------+
| Purchasing, i.e. Medical Supplies purchases      | N                 |
+--------------------------------------------------+-------------------+
| Provider Identifiers                             | N                 |
+--------------------------------------------------+-------------------+
| Unique Patient Identifiers                       | N                 |
+--------------------------------------------------+-------------------+
| Plan Identifiers                                 | N                 |
+--------------------------------------------------+-------------------+
| Employer Identifiers (Final Rule scheduled for   | Y                 |
| July '04)                                        |                   |
+--------------------------------------------------+-------------------+
| Advance Beneficiary Notification                 | N                 |
+--------------------------------------------------+-------------------+
| Electronic Signatures (being addressed by        | N                 |
| Text-Based Reports Workgroup)                    |                   |
+--------------------------------------------------+-------------------+

**[Information Exchange Requirements (IERs)]{.underline}** *Using the
table at appendix A, list the IERs involved when using this vocabulary.*

  -----------------------------------------------------------------------
  Beneficiary Financial

  Cost Accounting Information

  Customer Health Care Information

  Encounter (Administrative) Data

  Referral Information

  Provider Demographics
  -----------------------------------------------------------------------

**[Team Members]{.underline}** *Team members' names and agency names
with phone numbers.*

  ------------------------------ ----------------------------------------
  Name                           Agency/Department

  **Cynthia Wark (Team Lead)**   HHS/CMS/OHS/CHI

  Alicia Bradford                HHS/CMS/OHS/CHI

  Lorraine Doo                   HHS/CMS/OHS/HIPAA Regs

  Stacey Stinson                 HHS/CMS/OFM

  Melanie Combs                  HHS/CMS/OFM

  Jim Krall                      HHS/CMS/OIS

  Patricia Bosley                HHS/CMS/OIS

  Mary Johnson                   VA/OI/HDI

  Jon Sandy                      VA/BD/VHA/CBO

  David McDaniel                 VA/BD/VHA/CBO

  Stephanie Mardon               VA/BD/VHA/CBO

  Derek Wang                     SSA

  Bob Hastings                   SSA

  Sherry McKenzie                DOD/TRICARE Management Activity/IM

  Dan Sawyer                     DOD/TRICARE Management Activity/IM
  ------------------------------ ----------------------------------------

**[Work Period]{.underline}** *Dates work began/ended.*

  ----------------------------------- -----------------------------------
  Start                               End

  October 2003                        November 2003
  ----------------------------------- -----------------------------------

**Part II -- Standards Adoption Recommendation**

##### Recommendation *Identify the solution recommended.*

The HIPAA approved transactions and codes set, both those currently
approved as well as future updates, are recommended for adoption.

+--------------------------------------------+-------------------------+
| **HIPAA Medical Code Sets**                | **HIPAA non-Medical     |
|                                            | Transactions and Code   |
|                                            | Sets (Internal and      |
|                                            | External)**             |
+--------------------------------------------+-------------------------+
| -   ICD-9-CM: Volumes 1 & 2 for diagnosis  | ASC X12N 837            |
|     codes                                  |                         |
|                                            | ASC X12N 820            |
| -   ICD-9-CM: Volume 3 for inpatient       |                         |
|     hospital procedures                    | ASC X12N 834            |
|                                            |                         |
| -   NDC: National Drug Codes for retail    | ASC X12N 835            |
|     pharmacy claims                        |                         |
|                                            | ASC X12N 270/271        |
| -   HCPCS and CPT-4^®^ for physician       |                         |
|     services and other health services     | ASC X12N 278            |
|                                            |                         |
| -   HCPCS for all other substances,        | ASC X12N 276/277        |
|     equipment, supplies, and other medical |                         |
|     supplies                               | NCPDP Telecommunication |
|                                            | Standards               |
| -   CDT^®^ for dental services             |                         |
|                                            |                         |
| -   NDC for retail pharmacy transactions   |                         |
|                                            |                         |
| -   ABC Codes for registered users         |                         |
|                                            |                         |
| -   Diagnostic Related Groups (DRGs)       |                         |
+--------------------------------------------+-------------------------+

**[Ownership Structure]{.underline}** *Describe who "owns" the standard,
how it is managed and controlled.*

+-----------------------------------------------------------------------+
| Maintenance and control for the HIPAA approved codes sets are as      |
| follows:                                                              |
|                                                                       |
| NCHS maintains ICD-9-CM;                                              |
|                                                                       |
| FDA maintains NDC codes;                                              |
|                                                                       |
| CMS maintains HCPCS codes;                                            |
|                                                                       |
| AMA owns and maintains CPT-4^®^ codes;                                |
|                                                                       |
| ADA owns and maintains CDT^®^ codes;                                  |
|                                                                       |
| Alternative Link owns and maintains ABC codes as well as the          |
| participant registration logs.                                        |
|                                                                       |
| CMS maintains DRG codes.                                              |
|                                                                       |
| FDA maintains NDC codes.                                              |
+-----------------------------------------------------------------------+

##### Summary Basis for Recommendation *Summarize the team's basis for making the recommendation (300 words or less).*

+-----------------------------------------------------------------------+
| The Billing/Financial workgroup was originally identified as a domain |
| with "**Terminologies used by other processes."** In the case of      |
| billing information, HIPAA has been identified as an existing         |
| regulatory process that is important to the electronic health record. |
| The code sets are maintained by a combination of government agencies, |
| professional organizations, and private industry. Therefore, the      |
| workgroup assigned to this domain was charged with verifying the      |
| adequacy of the present terminologies used by the outside process of  |
| HIPAA.                                                                |
|                                                                       |
| Health plans (insurers) and health care providers who transmit any of |
| the designated HIPAA transactions electronically within the Federal   |
| Government (Medicare, Medicaid, Veteran's Administration, Department  |
| of Defense's Military Health System and TRICARE Program, Indian       |
| Health Service, etc.) or external to it, are considered HIPAA covered |
| entities and were required to be compliant with HIPAA transactions    |
| and code sets as of October 16, 2003. Therefore, HIPAA covered        |
| entities within the federal government have already adopted the HIPAA |
| approved transactions and code sets.                                  |
|                                                                       |
| In addition to the HIPAA transaction and code set standards, the      |
| workgroup has identified ICD-10-CM and ICD-10-PCS as standards to be  |
| considered. The workgroup is aware that the NCVHS Standards and       |
| Security Subcommittee (SSS) has these classification systems under    |
| study and therefore will follow this work as it evolves.              |
|                                                                       |
| Claims attachments are considered out of scope due to the expected    |
| publication of the Attachment NPRM by HHS in 2004. Work is underway   |
| between the HL7^®^ Attachments Special Interest Group and CHI staff   |
| to map and align CHI clinical standards with the proposed HL7^®^      |
| claims attachment standard. Therefore, until this work has evolved    |
| further, the workgroup considers this transaction out of scope.       |
|                                                                       |
| The X12 837 transaction could be used for certificates of medical     |
| necessity, however it is not a HIPAA approved transaction/code set.   |
| There are no federal agencies using an electronic standard for data   |
| or structure related to certificates of medical necessity. Therefore, |
| no recommendation is being made to adopt a standard in this area.     |
|                                                                       |
| The workgroup performed an analysis of alternatives that might be     |
| available for appeals and is not making a recommendation for any      |
| standard in this area. (see analysis under Options Considered         |
| section).                                                             |
+-----------------------------------------------------------------------+

**[Conditional Recommendation]{.underline}** *If this is a conditional
recommendation, describe conditions upon which the recommendation is
predicated.*

  -----------------------------------------------------------------------
  There are no conditions on the use of HIPAA approved code sets and
  transactions.

  -----------------------------------------------------------------------

##### 

##### Approvals & Accreditations

*Indicate the status of various accreditations and approvals:*

+-----------------------------+---------------+------------+-----------+
| Approvals                   | Yes/Approved  | Applied    | Not       |
|                             |               |            | Approved  |
| &                           |               |            |           |
|                             |               |            |           |
| Accreditations              |               |            |           |
+-----------------------------+---------------+------------+-----------+
| Full SDO Ballot             | N/A           |            |           |
+-----------------------------+---------------+------------+-----------+
| ANSI                        | only the ADA  |            |           |
|                             | (CDT®)        |            |           |
+-----------------------------+---------------+------------+-----------+

**[Options Considered]{.underline}** *Inventory solution options
considered and summarize the basis for not recommending the
alternative(s). SNOMED must be specifically discussed.*

+-----------------------------------------------------------------------+
| The alternatives identified have been those code sets adopted under   |
| HIPAA:                                                                |
|                                                                       |
| 1.  HCPCS and CPT-4^®^, Healthcare Common Procedure Coding System and |
|     Current Procedural Terminology for physician services and other   |
|     health services                                                   |
|                                                                       |
| 2.  HCPCS for all other substances, equipment, supplies and other     |
|     medical supplies                                                  |
|                                                                       |
| 3.  ICD-9-CM, Vols 1&2 for diagnosis codes                            |
|                                                                       |
| 4.  ICD-9-CM, Vol 3 for inpatient hospital procedures                 |
|                                                                       |
| 5.  NDC, National Drug Codes for retail pharmacy claims               |
|                                                                       |
| 6.  CDT^®^, Common Dental Terminology for dental services             |
|                                                                       |
| 7.  DRG, Diagnostic Related Groups                                    |
|                                                                       |
| 8.  Code sets internal to the approved X12 and NCPDP^®^ transaction   |
|     implementation guides                                             |
|                                                                       |
| 9.  ABC codes                                                         |
|                                                                       |
| > Additional codes sets identified*:*                                 |
|                                                                       |
| 10. ICD-10-CM                                                         |
|                                                                       |
| 11. ICD-10-PCS                                                        |
+-----------------------------------------------------------------------+

**[ABC Codes:]{.underline}**

The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
gave the Secretary of the U.S. Department of Health and Human Services
the authority to permit exceptions from HIPAA transaction and code set
standards to test proposed modifications to those standards.

Advanced Billing Concept codes, or ABC codes, are a proposed
modification that identifies alternative medicine, nursing and other
integrative healthcare interventions.

HHS Secretary Tommy Thompson approved nationwide voluntary testing of
ABC codes to demonstrate their value when used in conjunction with HCPCS
Level I and II codes (e.g., the American Medical Association's Current
Procedural Terminology or CPT^®^ codes).

Note: The CHI Nursing Domain is recommending standards for nursing
information. Therefore, the use of the ABC codes are limited to use in
HIPAA approved transactions to fulfill billing/financial functions.
Standards identified by the nursing workgroup apply to all non-billing
related functions.

**[Appeals:]{.underline}**

An analysis of current activities related to Medicare appeals shows no
local electronic EDI formats being used today at the Medicare
contractors for fee-for-service appeals. Carriers are currently
accepting first level appeals over the phone.

CMS is currently working to develop a \"Medicare Appeals System\" that
will eventually allow CMS and its contractors to work with
electronic/imaged case files. However, the full implementation is
projected to be several years away. The workgroup recommends revisiting
this area when an electronic case file is implemented.

For a health care claim, it would be possible to file an appeal using
the 837 claim format although codes have not been identified specific to
appeals. Appeals could be submitted as claim adjustment requests with
codes identifying the type of appeal/adjustment being requested or a
generic appeal code that would leave it to the payer to determine what
level of appeal was appropriate.

Medicare could implement an automated appeal request for providers.
Medicare has an established process for provider submission of
adjustment bills to intermediaries, however there is no comparable
process for carriers. Providers are not currently allowed to submit
adjustment bills to carriers. Manual changes and system changes would be
needed to support that action.

The Department of Veterans Affairs (VA) presently does not have an
electronic capability to submit appeals to third party payers on claims
they prepare. Additionally, VA does not have the capacity to accept
electronic appeals on claims they process for payments.

For DoD, there is no healthcare enterprise standard set of appeals data
or standard appeals transaction used for submitting claims appeals
involving direct care or purchased care (contracted managed care)
aspects of the DoD TRICARE claims appeals process. There are
standardized processes, but no standardized data or transactions. In
many cases, appeals are submitted in letter format.

Due to the aforementioned considerations, the workgroup does not
recommend any standard to be adopted for appeals.

**[Certificate of Medical Necessity:]{.underline}**

There is a standard available that could meet some medical necessity
electronic processing needs: ASC X12n837 professional version of 4010a1
(professional claim under HIPAA). This standard can accommodate
information on ambulance, chiropractic, durable medical equipment and
oxygen that is handled under the Medicare electronic National Standard
Format (NSF) and its accompanying electronic attachments. This is not a
HIPAA covered transaction and the standard is not currently in use,
therefore no recommendation is being made in this area.

**[Current Deployment]{.underline}**

+-----------------------------------------------------------------------+
| *Summarize the degree of market penetration today; i.e., where is     |
| this solution installed today?*                                       |
|                                                                       |
| *What number of or percentage of relevant vendors have adopted the    |
| standard?*                                                            |
|                                                                       |
| *What number or percentage of healthcare institutions have adopted    |
| the standard?*                                                        |
|                                                                       |
| *What number or percentage of federal agencies have adopted the       |
| standard?*                                                            |
|                                                                       |
| *Is the standard used in other countries?*                            |
|                                                                       |
| *Are there other relevant indicators of market acceptance?*           |
+-----------------------------------------------------------------------+

**Part III -- Adoption & Deployment Information**

*Provide all information gathered in the course of making the
recommendation that may assist with adoption of the standard in the
federal health care sector. This information will support the work of an
implementation team.*

**[Existing Need & Use Environment]{.underline}**

###### Measure the need for this standard and the extent of existing exchange among federal users. Provide information regarding federal departments and agencies use or non-use of this health information in paper or electronic form, summarize their primary reason for using the information, and indicate if they exchange the information internally or externally with other federal or non-federal entities.

Column A: Agency or Department Identity (name)

Column B: Use data in this domain today? (Y or N)

Column C: Is use of data a core mission requirement? (Y or N)

Column D: Exchange with others in federal sector now? (Y or N)

Column E: Currently exchange paper or electronic (P, E, B (both), N/A)

Column F: Name of paper/electronic vocabulary, if any (name)

Column G: Basis/purposes for data use (research, patient care, benefits)

  ---------------------------------------------------------------------------------------------
  **Department/Agency**   **B**   **C**   **D**   **E**   **F**                  **G**
  ----------------------- ------- ------- ------- ------- ---------------------- --------------
  Department of Veterans  Y       Y                                              
  Affairs                                                                        

  Department of Defense   Y       Y       Y       B                              

  HHS Office of the       N       N                                              
  Secretary                                                                      

  Administration for                                                             
  Children and Families                                                          
  (ACF)                                                                          

  Administration on Aging                                                        
  (AOA)                                                                          

  Agency for Healthcare                                                          
  Research and Quality                                                           
  (AHRQ)                                                                         

  Agency for Toxic                                                               
  Substances and Disease                                                         
  Registry (ATSDR)                                                               

  Centers for Disease                                                            
  Control and Prevention                                                         
  (CDC)                                                                          

  Centers for Medicare    Y       Y       Y       B                              
  and Medicaid Services                                                          
  (CMS)                                                                          

  Food and Drug                                                                  
  Administration (FDA)                                                           

  Health Resources and                                                           
  Services Administration                                                        
  (HRSA)                                                                         

  Indian Health Service   Y       Y       Y       B                              
  (IHS)                                                                          

  National Institutes of                                                         
  Health (NIH)                                                                   

  Substance Abuse and                                                            
  Mental Health Services                                                         
  Administration (SAMHSA)                                                        

  Social Security         Y       Y       Y       B                              
  Administration                                                                 

  Department of                                                                  
  Agriculture                                                                    

  State Department                                                               

  US Agency for                                                                  
  International                                                                  
  Development                                                                    

  Justice Department              Y       Y       N/A     BOP uses a subset of   
                                                          ICD-10 codes for       
                                                          internal use. No       
                                                          exchange of info       
                                                          outside of BOP.        

  Treasury Department                                                            

  Department of Education                                                        

  General Services                                                               
  Administration                                                                 

  Environmental                                                                  
  Protection Agency                                                              

  Department of Housing &                                                        
  Urban Development                                                              

  Department of                                                                  
  Transportation                                                                 

  Homeland Security                                                              
  ---------------------------------------------------------------------------------------------

##### 

+-----------------------------------------------------------------------+
| **Number of Terms**                                                   |
|                                                                       |
| *Quantify the number of vocabulary terms, range of terms or other     |
| order of magnitude.*                                                  |
|                                                                       |
| See HIPAA website for details on range of terms.                      |
|                                                                       |
| *How often are terms updated?*                                        |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| ##### Range of Coverage                                               |
|                                                                       |
| #####                                                                 |
|                                                                       |
| ##### *Within the recommended vocabulary, what portions of the s      |
| tandard are complete and can be implemented now? (300 words or less)* |
|                                                                       |
| See HIPAA website for details on range of coverage.                   |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| ###### **                                                             |
| Acquisition:** How are the data sets/codes acquired and use licensed? |
|                                                                       |
| See <http://cms.hhs.gov/hipaa/hipaa2/education/infoserie/4-tcs.doc>   |
| for details on acquisition and accompanying information.              |
|                                                                       |
| > Provider Taxonomy Codes:                                            |
| >                                                                     |
| > <http://www.wpc-edi.com/codes/Codes.asp>                            |
| >                                                                     |
| > Current Dental Terminology Codes:                                   |
| >                                                                     |
| > <http://www.ada.org/>                                               |
| >                                                                     |
| > Current Procedural Terminology Codes:                               |
| >                                                                     |
| > <http://www.ama-assn.org/>                                          |
| >                                                                     |
| > Healthcare Common Procedure Coding System (HCPCS)                   |
| >                                                                     |
| > <http://www.cms.gov/medicare/hcpcs>                                 |
| >                                                                     |
| > Diagnostic Related Group Numbers: U.S. Government Printing Office   |
| >                                                                     |
| > National Drug Code: Federal Drug Listing Branch HFN-315             |
| >                                                                     |
| > Advanced Billing Concept Codes:                                     |
| >                                                                     |
| > http://www.alternativelink.com/ali/home/default.asp                 |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| ###### **Cost**                                                       |
|                                                                       |
| ######                                                                |
|                                                                       |
| ###### What is the direct cost to obtain permission to u              |
| se the data sets/codes? (licensure, acquisition, other external data  |
| sets required, training and education, updates and maintenance, etc.) |
|                                                                       |
| See HIPAA website for details on costs, licensure and acquisition.    |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **Systems Requirements**                                              |
|                                                                       |
| *Is the standard associated with or limited to a specific hardware or |
| software technology or other protocol?*                               |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **Guidance:** *What public domain and implementation and user guides, |
| implementation tools or other assistance is available and are they    |
| approved by the SDO?*                                                 |
|                                                                       |
| *Is a conformance standard specified? Are conformance tools           |
| available?*                                                           |
|                                                                       |
| See HIPAA website for guidance and implementation tools.              |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **Maintenance:** *How do you coordinate inclusion and maintenance     |
| with the standards developer/owners?*                                 |
|                                                                       |
| *What is the process for adding new capabilities or fixes?*           |
|                                                                       |
| *What is the average time between versions?*                          |
|                                                                       |
| Versions of standards under HIPAA require regulation. Therefore,      |
| average time between use of updated versions varies according to the  |
| regulatory process.                                                   |
|                                                                       |
| *What methods or tools are used to expedite the standards development |
| cycle?*                                                               |
|                                                                       |
| *How are local extensions, beyond the scope of the standard,          |
| supported if at all?*                                                 |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **Customization:** *Describe known implementations that have been     |
| achieved without user customization, if any.*                         |
|                                                                       |
| *If user customization is needed or desirable, how is this achieved?  |
| (e.g, optional fields, interface engines, etc.)*                      |
|                                                                       |
| > ***What about "local codes" for services and supplies?***           |
|                                                                       |
| The purpose of the HIPAA transactions and code sets rules is          |
| standardization and simplification. Therefore, it is only logical     |
| that HIPAA does not permit nonstandard codes.                         |
|                                                                       |
| Local codes are codes that different payer organizations have devised |
| to handle unique circumstances for their own special purposes.        |
|                                                                       |
| > Many health plans, including state Medicaid programs, have adopted  |
| > local codes in response to specific variations in their programs or |
| > business rules. Under HIPAA, all local medical service codes must   |
| > be replaced with the appropriate HCPCS and CPT-4^®^ codes. In       |
| > addition, a number of new codes have been added to HCPCS to         |
| > accommodate items that did not have codes before.                   |
| >                                                                     |
| > Plans use local codes for a variety of reasons. Some codes          |
| > designate a specific place of service that has higher reimbursement |
| > rates. Others might identify a particular pilot project or benefit  |
| > package. Still other local codes bundle services to create a        |
| > separate reimbursement structure.                                   |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **Mapping Requirements**                                              |
|                                                                       |
| Describe the extent to which user agencies will likely need to        |
| perform mapping from internal codes to this standard.                 |
|                                                                       |
| -   Country Codes: FIPS vs. ISO                                       |
|                                                                       |
| -   Individual Relationship Codes: Internal vs. X12                   |
|                                                                       |
| Identify the tools available to user agencies to automate or          |
| otherwise simplify mapping from existing codes to this standard.      |
|                                                                       |
| The National Imagery and Mapping Agency (NIMA) has drafted a proposed |
| mapping document between FIPS 10-4 and ISO 3166 country codes. This   |
| document has been initially identified as FIPS 10-5.                  |
+-----------------------------------------------------------------------+

Compatibility

Identify the extent of off-the-shelf conformity with other standards and
requirements:

+----------------------------------------+-------+---------+----------+
| ##                                     | ####  | #####   | Yes with |
| ###### Conformity with other Standards | ####  | ### No  | e        |
|                                        | Yes ( |         | xception |
|                                        | 100%) | ######  |          |
|                                        |       | ## (0%) |          |
+----------------------------------------+-------+---------+----------+
| NEDSS requirements                     |       |         |          |
+----------------------------------------+-------+---------+----------+
| HIPAA standards                        | # Y   |         |          |
+----------------------------------------+-------+---------+----------+
| HL7 2.x                                |       |         |          |
+----------------------------------------+-------+---------+----------+

+-----------------------------------------------------------------------+
| **[Implementation Timeframe]{.underline}**                            |
|                                                                       |
| *Estimate the number of months required to deploy this standard;      |
| identify unique considerations that will impact deployment            |
| schedules.*                                                           |
|                                                                       |
| N/A                                                                   |
|                                                                       |
| *If some data sets/code sets are under development, what are the      |
| projected dates of completion/deployment?*                            |
|                                                                       |
| N/A                                                                   |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **[Gaps]{.underline}**                                                |
|                                                                       |
| *Identify the gaps in data, vocabulary or interoperability.*          |
|                                                                       |
| There are no gaps identified.                                         |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **Obstacles**                                                         |
|                                                                       |
| *What obstacles, if any, have slowed penetration of this standard?    |
| (technical, financial, and/or cultural)*                              |
+-----------------------------------------------------------------------+

***[Appendix A]{.underline}***

**[Information Exchange Requirements (IERs)]{.underline}**

  -----------------------------------------------------------------------
  **Information Exchange              **Description of IER**
  Requirement**                       
  ----------------------------------- -----------------------------------
  Beneficiary Financial / Demographic Beneficiary financial and
  Data                                demographic data used to support
                                      enrollment and eligibility into a
                                      Health Insurance Program.

  Beneficiary Inquiry Information     Information relating to the
                                      inquiries made by beneficiaries as
                                      they relate to their interaction
                                      with the health organization .

  Beneficiary Tracking Information    Information relating to the
                                      physical movement or potential
                                      movement of patients,
                                      beneficiaries, or active duty
                                      personnel due to changes in level
                                      of care or deployment, etc.

  Body of Health Services Knowledge   Federal, state, professional
                                      association, or local policies and
                                      guidance regarding health services
                                      or any other health care
                                      information accessible to health
                                      care providers through research,
                                      journals, medical texts, on-line
                                      health care data bases,
                                      consultations, and provider
                                      expertise. This may include: (1)
                                      utilization management standards
                                      that monitor health care services
                                      and resources used in the delivery
                                      of health care to a customer; (2)
                                      case management guidelines; (3)
                                      clinical protocols based on
                                      forensic requirements; (4) clinical
                                      pathway guidelines; (5) uniform
                                      patient placement criteria, which
                                      are used to determine the level of
                                      risk for a customer and the level
                                      of mental disorders (6) standards
                                      set by health care oversight bodies
                                      such as the Joint Commission for
                                      Accreditation of Health Care
                                      Organizations (JCAHO) and Health
                                      Plan Employer Data and Information
                                      Set (HEDIS); (7) credentialing
                                      criteria; (8) privacy act
                                      standards; (9) Freedom of
                                      Information Act guidelines; and
                                      (10) the estimated time needed to
                                      perform health care procedures and
                                      services.

  Care Management Information         Specific clinical information used
                                      to record and identify the
                                      stratification of Beneficiaries as
                                      they are assigned to varying levels
                                      of care.

  Case Management Information         Specific clinical information used
                                      to record and manage the
                                      occurrences of high-risk level
                                      assignments of patients in the
                                      health delivery organization..

  Clinical Guidelines                 Treatment, screening, and clinical
                                      management guidelines used by
                                      clinicians in the decision-making
                                      processes for providing care and
                                      treatment of the
                                      beneficiary/patient.

  Cost Accounting Information         All clinical and financial data
                                      collected for use in the
                                      calculation and assignment of costs
                                      in the health organization.

  Customer Approved Care Plan         The plan of care (or set of
                                      intervention options) mutually
                                      selected by the provider and the
                                      customer (or responsible person).

  Customer Demographic Data           Facts about the beneficiary
                                      population such as address, phone
                                      number, occupation, sex, age, race,
                                      mother\'s maiden name and SSN,
                                      father\'s name, and unit to which
                                      Service members are assigned.

  Customer Health Care Information    All information about customer
                                      health data, customer care
                                      information, and customer
                                      demographic data, and customer
                                      insurance information. Selected
                                      information is provided to both
                                      external and internal customers
                                      contingent upon confidentiality
                                      restrictions. Information provided
                                      includes immunization
                                      certifications and reports, birth
                                      information, and customer medical
                                      and dental readiness status.

  Customer Risk Factors               Factors in the environment or
                                      chemical, psychological,
                                      physiological, or genetic elements
                                      thought to predispose an individual
                                      to the development of a disease or
                                      injury. Includes occupational and
                                      lifestyle risk factors and risk of
                                      acquiring a disease due to travel
                                      to certain regions.

  Encounter (Administrative) Data     Administrative and Financial data
                                      that is collected on patients as
                                      they move through the healthcare
                                      continuum. This information is
                                      largely used for administrative and
                                      financial activities such as
                                      reporting and billing.

  Improvement Strategy                Approach for advancing or changing
                                      for the better the business rules
                                      or business functions of the health
                                      organization. Includes strategies
                                      for improving health organization
                                      employee performance (including
                                      training requirements), utilization
                                      management, workplace safety, and
                                      customer satisfaction.

  Labor Productivity Information      Financial and clinical (acuity,
                                      etc.) data used to calculate and
                                      measure labor productivity of the
                                      workforce supporting the health
                                      organization.

  Health Organization Direction       Goals, objectives, strategies,
                                      policies, plans, programs, and
                                      projects that control and direct
                                      health organization business
                                      function, including (1) direction
                                      derived from DoD policy and
                                      guidance and laws and regulations;
                                      and (2) health promotion programs.

  Patient Satisfaction Information    Survey data gathered from
                                      beneficiaries that receive services
                                      from providers that the health
                                      organization wishes to use to
                                      measure satisfaction.

  Patient Schedule                    Scheduled procedure type, location,
                                      and date of service information
                                      related to scheduled interactions
                                      with the patient.

  Population Member Health Data       Facts about the current and
                                      historical health conditions of the
                                      members of an organization.
                                      (Individuals\' health data are
                                      grouped by the employing
                                      organization, with the expectation
                                      that the organization\'s operations
                                      pose similar health risks to all
                                      the organization\'s members.)

  Population Risk Reduction Plan      Sets of actions proposed to an
                                      organization commander for his/her
                                      selection to reduce the effect of
                                      health risks on the organization\'s
                                      mission effectiveness and member
                                      health status. The proposed actions
                                      include: (1) resources required to
                                      carry out the actions, (2) expected
                                      mission impact, and (3) member\'s
                                      health status with and without the
                                      actions.

  Provider Demographics               Specific demographic information
                                      relating to both internal and
                                      external providers associated with
                                      the health organization including
                                      location, credentialing, services,
                                      ratings, etc.

  Provider Metrics                    Key indicators that are used to
                                      measure performance of providers
                                      (internal and external) associated
                                      with the health organization.

  Referral Information                Specific clinical and financial
                                      information necessary to refer
                                      beneficiaries to the appropriate
                                      services and level of care.

  Resource Availability               The accessibility of all people,
                                      equipment, supplies, facilities,
                                      and automated systems needed to
                                      execute business activities.

  Tailored Education Information      Approved TRICARE program education
                                      information / materials customized
                                      for distribution to existing
                                      beneficiaries to provide
                                      information on their selected
                                      health plan. Can also include risk
                                      factors, diseases, individual
                                      health care instructions, and
                                      driving instructions.
  -----------------------------------------------------------------------