Half­way home

Just a few bumps on the road to new data stan­dards

Modern Healthcare - - Information Edge - Joseph Conn

In Jan­uary 2009, HHS pub­lished a fi­nal rule out­lin­ing the steps the health­care in­dus­try must take to update the elec­tronic data trans­mis­sions stan­dards used by the fi­nan­cial sys­tems of hos­pi­tals, physi­cian of­fices, claims clear­ing­houses and pay­ers.

The 34-page fi­nal rule called for a 36-month roll­out pe­riod for the new data ex­change stan­dards and urged all af­fected health­care or­ga­ni­za­tions to im­me­di­ately be­gin tak­ing steps to­ward con­ver­sion to the new stan­dards by Jan. 1, 2012.

So, how is it go­ing thus far? Fairly well, ac­cord­ing to a ma­jor­ity—but not all—of the in­dus­try ex­perts con­tacted for this story.

At this point, a lit­tle past half­way be­tween the is­suance of the rule and its fi­nal com­pli­ance dead­line, providers, clear­ing­houses and health plans as well as the CMS are mov­ing ahead with mod­i­fi­ca­tions to their in­for­ma­tion technology sys­tems to ac­com­mo­date the tran­si­tion from the cur­rent fam­ily of trans­ac­tion stan­dards, known as ASC X12 Ver­sion 4010, to the new stan­dards, ASC X12 Ver­sion 5010.

The 5010 stan­dards bear the name of the Ac­cred­ited Stan­dards Com­mit­tee X12, which is a U.S. stan­dards devel­op­ment or­ga­ni­za­tion ac­cred­ited in 1979 by the Amer­i­can Na­tional Stan­dards In­sti­tute to de­velop a uni­form frame­work for elec­tronic data in­ter­change. ASC X12 has pro­duced more than 300 EDI stan­dards for govern­ment and mul­ti­ple in­dus­tries, in­clud­ing health­care.

Denise Buen­ning is a se­nior ad­viser and team leader at the Of­fice of E-Health Stan­dards and Ser­vices at the CMS for the con­ver­sion to 5010.

The CMS is “right on tar­get” to make the switch to Ver­sion 5010 in its own Medi­care feefor-ser­vice pro­gram, Buen­ning says.

“They ex­pect to be test­ing ex­ter­nally in Jan­uary next year,” he says. “All sys­tems are go.” And else­where in the in­dus­try, “all the feed­back we’re get­ting, no­body has stepped up and said we’re hav­ing an is­sue on this.”

If there is one dicey area in the changeover to 5010, ac­cord­ing to Buen­ning, it may be with state Med­i­caid pro­grams.

In com­ments dur­ing rule­mak­ing, some states said that they needed to present fund­ing re­quests for the con­ver­sion to their state leg­is­la­tures, but to do so, they needed a fi­nal rule in hand. A pro­posed rule on 5010, is­sued by HHS in Au­gust 2008, wasn’t good enough, they said. That’s caused some de­lays, ac­cord­ing to the states.

“We’ve done some ini­tial scan­ning of the states,” Buen­ning says. “We’re hear­ing feed­back they’re try­ing to be ready, but they’re def­i­nitely lag­ging. They have some chal­lenges.”

Buen­ning says the CMS is work­ing with the states to pro­vide guid­ance and re­sources if nec­es­sary to see that they get the help they need.

The 5010 stan­dards, like the Ver­sion 4010 group in cur­rent use, pro­vide uni­form mes­sag­ing ca­pa­bil­i­ties for health­care trans­ac­tions such as check­ing the el­i­gi­bil­ity of a pa­tient for in­surance ben­e­fits, the sub­mis­sion and pay­ment of claims and any in­quiries and re­sponses re­gard­ing the sta­tus of claims in process.

The new 5010 stan­dards pro­vide a much needed up­grade—the first full ver­sion change in trans­ac­tions stan­dards in more than a decade. They re­flect many of the hun­dreds of in­dus­try re­quests dur­ing the in­ter­reg­num for im­prove­ments to 4010 stan­dards that aim to pro­vide users with clearer in­struc­tions, re­duce am­bi­gu­ity among com­mon data el­e­ments used in dif­fer­ent trans­ac­tions, and elim­i­nate re­dun­dant and un­nec­es­sary data el­e­ments, ac­cord­ing to an Amer­i­can Med­i­cal As­so­ci­a­tion primer.

Some of the lesser changes in Ver­sion 5010 are merely for good house­keep­ing, for ex­am­ple, stan­dard­iz­ing the lo­ca­tion of in­for­ma­tion in what were called im­ple­men­ta­tion guide­lines in the 4010 stan­dards, but are called tech­ni­cal re­ports in the 5010 stan­dards.

But the cru­cial change made in the 5010 stan­dard is that it ac­com­mo­dates the switch from the In­ter­na­tional Clas­si­fi­ca­tion of Dis­eases Ver­sion 9 fam­ily of clin­i­cal codes to the far more ro­bust and de­tailed ICD-10 codes. The dead­line for the U.S. launch of ICD-10 is Oct. 1, 2013, set in a sep­a­rate HHS rule.

In 2000, HHS pub­lished the trans­ac­tions rule for the Health In­surance Porta­bil­ity and Ac­count­abil­ity Act of 1996, adopt­ing nine ASC X12 trans­ac­tion stan­dards for health­care. HHS has des­ig­nated ASC X12 as a stan­dards devel­op­ment or­ga­ni­za­tion to con­tinue to man­age EDI stan­dards un­der HIPAA.

No mean­ing­ful use, yet

Ven­dors will not be re­quired to demon­strate Ver­sion 5010 ca­pa­bil­i­ties when they sub­mit their elec­tronic health-record sys­tems for cer­ti­fi­ca­tion as el­i­gi­ble for fed­eral sub­sidy pay­ments un­der Stage I of mean­ing­ful-use cri­te­ria pur­suant to the Amer­i­can Re­cov­ery and Rein­vest­ment Act, com­monly known as the stim­u­lus law.

A pro­posed rule for the first round of mean­ing­ful-use cri­te­ria un­der the stim­u­lus law was is­sued by HHS in De­cem­ber 2009. It called for test­ing an IT sys­tem’s claims and el­i­gi­bil­ity func­tions, but those re­quire­ments were dropped in a sim­pli­fied fi­nal rule HHS is­sued on July 13.

Still, cer­ti­fi­ca­tion cri­te­ria for ad­min­is­tra­tive claims han­dling are ex­pected to reap-

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