# Presentation: 623778

## HIPAA Transactions and Code Sets“But Wait, There’s More!”

**David. A. Feinberg, C.D.P.**
**President, Rensis Corporation**
**206-617-1717**
_**DAFeinberg@computer.org**_

## David A. Feinberg, C.D.P.

- Consultant -- Healthcare Interfaces and EDI
- Member, Accredited Standards Committee X12 and its Insurance Subcommittee (X12N)
- Member, Health Level Seven (HL7)
- Co-Chair, X12N HIPAA Implementation Work Group
- Member, HL7 Attachments Special Interest Group (ASIG) and X12N Patient Information Work Group (TG2/WG9)
- Member, HL7 Image Integration Special Interest Group (IISIG) and DICOM Image Integration Group (WG20)
- Member, concluded HL7 Master Person Index Mediation Special Interest Group (MPISIG)
- Commercial and Technology Arbitrator, American Arbitration Association

## Administrative Simplification

- 	Through the standardization of data elements, codes, and identifiers for listed transactions _and attachments_, establishes the next baseline for using computing and automation to further improve healthcare ...
-      		 effectiveness
-      		 affordability
-      		 profitability

## Administrative Simplification

**National standards for efficient and electronic administrative and financial health care transactions**
- Recommendations, and ultimately, regulations for privacy legislation
**Recommendations for electronic medical records**

## Topics

- First Transactions and Code Sets Rule (HIPAA-1)
- Identifiers
- Claims and other Attachments
- HIPAA-2
- Electronic Medical Records

## Topics

**First Transactions and Code Sets Rule (HIPAA-1)**
- 	Identifiers
- 	Claims and other Attachments
- 	HIPAA-2
- 	Electronic Medical Records

## HIPAA Medical Code Sets

- Diagnoses -- ICD-9-CM
- Procedures
- Physician Services -- CPT-4 and CDT-3
- Inpatient Services -- ICD-9-CM
- Other Services -- 	HCPCS, without “D”,
- 					“J”, and local codes
- Drugs -- NDC   *{being modified}*
- Other Items -- HCPCS

## Other HIPAA Code Sets

- Defined by ...
- Implementation Guides
- External Code Sources,  for example,
- CMS [agency formerly known as HCFA]
- Data Content Committees: NUBC, NUCC, ADA
- Other sources,  for example,
- Claim Status and Adjustment Reason Codes Committee
- Postal Service
- International Standards Organization (ISO)
- Logical Observation Identifier Names and Codes (LOINC)

## HIPAA-1 Transactions

- P
- R
- O
- V
- I
- D
- E
- R
- S

- P
- A
- Y
- E
- R
- S

- S
- P
- O
- N
- S
- O
- R
- S

- Enrollment

- Premium Pmt

## HIPAA-1 Transactions

**HIPAA**		45 CFR		_**Implementation**_
_**Transaction**__	__Part 162__	__	__**Guide**__	__	__	__Standard_
**Claim - Prof.**	   K, R		**X12N  X098**		X12  837
**Claim - Inst.**	   K, R		**X12N  X096**		X12  837
**Claim - Dent.**	   K, R		**X12N  X097**		X12  837
**Claim - Retail Rx****	**   K, R		NCPDP Standards     **Telecommunications**
- 							       **Batch**
**Eligibility**	     L		**X12N  X092**		X12  270 & 271
**Referral**		     M		**X12N  X094**		X12  278
**Claim Status**	     N		**X12N  X093**		X12  276 & 277
**Enrollment**	     O		**X12N  X095**		X12  834
**Remittance**	     P		**X12N  X091**		X12  835
**Premium Pmt.**	     Q		**X12N  X061**		X12  820

## HIPAA Transactions

- Mandatory **Federal Regulations** [“Rules”]
- 			*which promulgate*
- Voluntarily adopted 		**Implementation Guides **{X12N}
- 			*which define precise uses of*
- Voluntarily adopted **ANSI Standards **{X12}

## X12 Example

- ST*270*123456~NM1*QC*1*DOE*JANE****MI*446765498A~NM1*P3*1*WELBY*MARCUS****NPI*1234567890~EQ*1***GP~SE*5*123456~
- 	ST*270*123456~
- 	NM1*QC*1*DOE*JANE****MI*446765498A~
- 	NM1*P3*1*WELBY*MARCUS****NPI*1234567890~
- 	EQ*1***GP~
- 	SE*5*123456~

## NM1 Segment

- Individual or Organization Name
- To supply the full name of an individual or
- organizational entity

*****

*****

*****

*****

*****

*****

*****

*****

**X     AN    2/80**

**NM109      67**
**ID Code**

*** **

**X      ID     2/2**

**NM110    706**
**Entity Relat.  Code**

**O      ID     2/3**

**NM111      98**
**Entity ID Code**

**~**

*****

## HIPAA-1 Transactions

***	****** ******The Addenda are published ...***
***	******	******   ******The Addenda are coming ...***
- _Modifications_ “necessary to permit compliance with the standards”; i.e., Implementation Guides
- _Maintenance_ (e.g., *errata*) to provide “technical corrections to an implementation specification”

## Topics

- 	First Transactions and Code Sets Rule (HIPAA-1)
**Identifiers**
- 	Claims and other Attachments
- 	HIPAA-2
- 	Electronic Medical Records

## HIPAA Identifiers

- Employer
- IRS’ Employer Identification Number (EIN)
- 9 position all-numeric
- no intelligence

## HIPAA Identifiers

- Provider
- Original proposal
- 8 position alphanumeric
- check digit included
- no intelligence
- Under consideration
- 10 position all-numeric
- check digit included
- no intelligence
- 							continued ...

## HIPAA Identifiers

- Provider  (continued)
- Completely replaces
- UPIN
- PIN
- Requires establishment of National Provider Identification System (NPS)
- Significant conversion and transition efforts for industry

## HIPAA Identifiers

- Health Plan
- Specifics still in drafting stage
- Expected to be based on HCFA’s PayerID / PlanID proposal of mid-1990’s
- 10 position all-numeric
- check digit included
- no intelligence

## HIPAA Identifiers

- Individual
- Emotionally controversial
- On hold pending privacy legislation and/or regulations
- Alternative may be Master Person Index (MPI) Mediation or other tactics (e.g., *peerreg****TM****)*
- Potential for significant conversion and transition efforts for industry

## Topics

- 	First Transactions and Code Sets Rule (HIPAA-1)
- 	Identifiers
**Claims and other Attachments**
- 	HIPAA-2
- 	Electronic Medical Records

## HIPAA Claims Attachments

- P
- R
- O
- V
- I
- D
- E
- R
- S

- P
- A
- Y
- E
- R
- S

- S
- P
- O
- N
- S
- O
- R
- S

- Enrollment

- Premium Pmt

## X12N

**X12N**
**HL7**
- and the
**Centers for Medicare and Medicaid Services**
- worked cooperatively
- to define the
**HIPAA Claims Attachments Transaction**

## Claims Attachment Transaction

- ISA			X12 Interchange Control Header
-   GS			X12 Functional Group Header
-      **ST 275**		X12 Transaction Set Header for Pt. Info.
-      ...
-      TRN
-      ...
-      **BIN**			X12 Binary segment _contains HL7 message_
**        ****MSH ORU**	**HL7** Message Header for Observed Result
-         ...
-         **OBX**		**HL7** Codified Result Value
-            |			  **| **        |             |         |       multiple iterations
**        ****OBX**		**HL7** Codified Result Value
-      SE			X12 Transaction Set Trailer
-   GE			X12 Functional Group Trailer
- IEA			X12 Interchange Control Trailer

## HIPAA Claims Attachments

- Defined by HL7 Attachments Special Interest Group (ASIG) in “Booklets”
- Values are identified using the **Logical Observation Identifier Names and Codes (LOINC)** code set
- Comprehensive [29,000 items to date]
- Adaptable
- Free

## Attachments Coding

- LOINC codes are grouped to define
- Attachment Types
-  (e.g., Ambulance, Emergency Department, Rehabilitative Services, Laboratory Results,Medications, Clinical Notes)
- Attachment Contents
- 	(e.g., Transport Origin, Transport Destination,Body Temperature, Temperature Reading Site,Respiration Rate, Medication Identification)

## Attachments Coding Hierarchy

- Attachment Type		          (e.g., Ambulance)
-          Question(s)		          (e.g., From Where?)
-                    Answer(s)	          (e.g., Address)

## HIPAA Claims Attachments

- Defined thus far
- Ambulance
- Emergency Department
- Rehabilitative Services
- Laboratory Results
- Medications
- Clinical Notes

## HIPAA Claims Attachments

- Still under consideration pending publication of NPRM
- Home Health   {currently being defined}
- Durable Medical Equipment
- Vision Services
- Skilled Nursing Facility
- End Stage Renal Disease
- ...

## Topics

- 	First Transactions and Code Sets Rule (HIPAA-1)
- 	Identifiers
- 	Claims and other Attachments
**HIPAA-2**
- 	Electronic Medical Records

## HIPAA-2

- 	Second, including Addenda, and subsequent rounds of HIPAA Transactions and Code Sets Regulations and Implementation Guides are being prepared using the procedures defined in the Memorandum of Understanding (MOU) between the Designated Standards Maintenance Organizations (_DSMO_):
- 			_SSO’s_			_DCC’s_
- 			X12N			NUBC
- 			NCPDP		NUCC
- 			HL7			ADA / DeCC.

## HIPAA-2 Transactions

- In process
- First Report of Injury
- Coordination of Benefit Verification
- Provider Information
- Eligibility / Enrollment Roster
- ...

## HIPAA-2 Attachments

- In process
- Durable Medical Equipment Certificate of Medical Need
- Under consideration
- Additional Clinical Attachments
- Additional Referral Attachments
- Enrollment Attachments
- Image Attachments  {HIPAA-**?**}
- ...

## Topics

- 	First Transactions and Code Sets Rule (HIPAA-1)
- 	Identifiers
- 	Claims and other Attachments
- 	HIPAA-2
**Electronic Medical Records**

## Electronic Medical Records

- HIPAA legislative mandate to ...
- “*study the issues related to the adoption of uniform data standards for patient medical record information and the electronic exchange of such information*”
- “*report ... recommendations and legislative proposals for such standards and electronic exchange*”
- 								continued ...

## Electronic Medical Records

- National Committee on Vital and Health Statistics (NCVHS)
- Chartered to carry out HIPAA electronic medical records mandate
- Expanded to better perform this and other HIPAA advisory duties
- Issued first Medical Records report on 6 July 2000:   _http://www.ncvhs.hhs.gov/hipaa000706.pdf_
- Next report containing suggested standards and adoption timings planned for early 2002

## Electronic Medical Records

- July, 2000, NCVHS Report
- Found major impediments
- Limited interoperability of health information systems
- Limited comparability of data exchanged among providers
- Need for better quality, accountability, and integrity of data
- Made ten high level recommendations -- most of which require explicit governmental funding

## HIPAA Further Information

- DHHS	_http://aspe.hhs.gov/admnsimp_
- X12N		_www.x12.org_   &   _www.wpc-edi.com/hipaa_
- NCPDP	_www.ncpdp.org_
- HL7		_www.hl7.org_	  {Attachments Special Interest Group}
- DSMO	_www.hipaa-dsmo.org_
- LOINC	_www.regenstrief.org/loinc/loinc.htm_
- NCVHS	_www.ncvhs.hhs.gov_
- glossary	_www.wedi.org/htdocs/resource/hipaa__**_**__glossary.pdf_

## HIPAA Transactions and Code Sets“But Wait, There’s More!”

*Comments?*
*Questions?*
*Smart Remarks?*

## HIPAA Transactions and Code Sets“But Wait, There’s More!”

**David. A. Feinberg, C.D.P.**
**President, Rensis Corporation**
**3662 SW Othello Street**
**Seattle, Washington  98126 **
**206-617-1717**
_**DAFeinberg@computer.org**_