JUN 25 1997
The Honorable Donna E. Shalala
Secretary of Health and Human Services
200
Independence Avenue, SW
Washington, DC 20201
Dear Secretary Shalala:
On behalf of the National Committee on Vital and Health Statistics (NCVHS), I am pleased to forward to you our recommendations relating to some of the health data standards being proposed for adoption in accordance with the administrative simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). As you are aware, HIPAA outlines a new approach to the adoption of data standards to support electronic data interchange in the health industry in the United States, in a framework that protects the privacy and security of health information. The law assigns to you the responsibility for adopting such standards by February 1998. It also asks you to provide detailed recommendations to Congress with respect to the privacy of individually identifiable health information by next August. The NCVHS is very pleased to provide support, advice and consultation to you in this effort.
To assist in carrying out our advisory responsibilities to you, the NCVHS, in collaboration with HHS, has held a number of public hearings to obtain input and advice from throughout the health industry, State government, and the research and public health communities. We have heard a great deal of input from the private and public sectors, and have synthesized that input into the following recommendations regarding the administrative simplification standards.
The NCVHS recommends that you adopt the following standards for transmission of administrative and financial transactions. In addition, we recommend that you specify the acceptable versions and implementation guides for these standards at the time the final rules are issued.
Pharmacy -- NCPDP Telecommunications Standard Format
Institutional -- ASC X12N Health Care Claim (837)
Professional -- ASC X12N Health Care Claim (837)
Dental -- ADA Implementation Guide for ASC X12N 837
* the X12N standard for claims includes standard information for coordination of benefits.
ASC X12N Benefit Enrollment and Maintenance (834)
ASC X12N Health Care Eligibility/Benefit Inquiry (270)
ASC X12N Health Care Eligibility/Benefit Information (271)
ASC X12N Health Care Claim Payment/Advice (835)
ASC X12N Consolidated Service Invoice/Statement (811)
ASC X12N Payment Order/Remittance Advice (820)
ASC X12N Report of Injury, Illness or Incident (148)
ASC X12N Health Care Claim Status Request (276)
ASC X12N Health Care Claim Status Notification (277)
ASC X12N Health Care Service Review Information (278)
The adoption of a standard for claim attachments is not due until next year, so we will make a timely recommendation for that transaction at a later time.
Although we recommend that institutional and professional claims should move to the ANSI X12N 837 standard, we recommend a strategy to ease the transition for providers and payers that currently rely on the older NSF or UB92 flat-file formats for electronic claims submissions. We have learned at the hearings that the financial health of providers is extremely sensitive to the timing of payments for claims submitted. As a result, there is some fear in the industry that pushing this transition to the 837 too rapidly could lead to financial failures if payments were delayed because of technical problems during the conversion. We recommend a transition strategy whereby willing trading partners, by mutual agreement, could continue to use existing flat-file mechanisms (NSF and UB92) to exchange claim transactions until February, 2002. Strict adherence to section 1175 of HIPAA (which forbids plans from refusing standard transactions or delaying payment on the grounds that a transaction is standard) will be expected and should be enforced.
The Committee has a long history of national leadership on health data content issues. We will review the information now being collected by HHS in the master data dictionary of transaction data elements and, once that is available, will formulate our recommendations. The Committee's recommendations on data content also will include specific recommendations for a process for changing, maintaining, and updating the standard data content specifications for the above administrative transactions. As part of our ongoing responsibilities, we will continue to advise you on the need for new data elements, as well as deletions and modifications to current data elements, for health care transactions.
At this time, we would like to make specific recommendations about several data elements. In a previous communication, we endorsed HCFA's NPI proposal for a unique identifier for providers. The Committee would like to endorse the HCFA proposed Payer ID as the national standard for the payer identifier. A recommendation on the individual identifier may follow, after the Committee has had opportunity to review and discuss the commissioned report on this topic.
The Committee recommends that diagnosis and procedure coding continue to use the current code sets because replacements will not be ready for implementation by the year 2000. ICD-9- CM diagnosis codes, ICD-9-CM Volume 3 procedure codes, and HCPCS (including CPT and CDT) procedure codes should be adopted as the standards to be implemented by the year 2000. Annual updates to ICD-9-CM and HCPCS should continue to follow the schedule currently used. In addition, we recommend that you advise industry to build and modify their information systems to accommodate a change to ICD-10-CM diagnostic coding in the year 2001 and a major change to a unified approach to coding procedures (yet to be defined) by the year 2002 or 2003. We recommend that you identify and implement an approach for procedure coding that addresses deficiencies in the current s 'stems, including issues of specificity and aggregation, unnecessary redundancy, and incomplete coverage of health care providers and settings. The committee will continue its leadership and participation in this endeavor.
Security standards will be recommended by the Committee after hearings are held on this topic. These hearings are currently scheduled for August.
We appreciate your national leadership in health data standards, electronic data interchange and privacy, and we are privileged to work with you on these issues.
Sincerely,
/s/
Don E. Detmer, M.D.
Chairman