EDI Issues Move Up the Priority List

Providers face multiple changes in the ways they use electronic data interchange to transmit claims and related transactions.

Health Data Management Magazine, 02/01/2010

A year has passed since the HITECH Act within the American Recovery and Reinvestment Act became law, with its enhanced protections of patient data and tens of billions of dollars to accelerate the adoption and use of electronic health records.

With all the noise around HITECH during the past year, it would be easy to miss a number of major issues-all affecting provider revenue streams-coming up fast in the electronic data interchange arena. For instance, the Jan. 1, 2012, compliance date for the HIPAA 5010 transaction sets for claims and related transactions is less than two years away. But the Department of Health and Human Services expects providers and payers to be done with internal testing by the end of 2010. Necessary software purchases need to be made by mid-2010. Providers also this year need to analyze the affect of the changeover on business processes. They also need to talk with vendors and insurers about their schedules for internal mediation and external testing.

There's a lot of work to get ready for 5010 and it doesn't all fall on claims management software vendors and clearinghouses, says Larry Watkins, managing consultant at Ingenix Consulting, a unit of revenue cycle management vendor Ingenix Inc., Eden Prairie, Minn. "The approach in the industry is that, 'My vendor and clearinghouse will take care of me,' that's very much what we're hearing now," he contends. "We're also hearing it from 'experts' who should know better."

Most changes from adoption of 5010-such as providing substantially more benefit information on insurance eligibility responses and better support for automated posting of remittance advice-will affect business processes more than technology ones, Watkins adds. "So, we are very concerned of the rhetoric in the industry that this is an I.T. problem."

Still, providers need to ensure their claims management vendor and clearinghouse are on top of 5010 compliance work, says Jim Denny, president and CEO at Navicure Inc., a Duluth, Ga.-based claims clearinghouse.

Provider compliance with 5010 "will be very dependent on the partners you have," he contends. "The partners should anticipate compliance won't be uniform on time and be able to handle everything."

Denny believes the government could ease 5010 migration and reduce problems by taking a staged approach to compliance. Insurers should be the first to certify compliance, followed by vendors and then providers, he advocates.

While the 5010 transactions will tighten up HIPAA-mandated claims formats that were supposed to serve as standards-but never did-there are other efforts to truly standardize electronic claims and related transactions (see story, this page).

Also on the horizon is the October 2013 deadline for transitioning from the three-decade-old ICD-9 diagnosis and procedure code sets to the vastly expanded ICD-10 code sets. These codes will affect a wide variety of information systems within an organization, impacting the documentation of care in clinical systems, the coding of financial transactions, and the aggregation of data in analytical systems. Providers and payers, observers say, need to start serious work on ICD-10 migration during 2010.

Further, a coding problem with Medicare's electronic prescription incentive program could cause providers to question the government's credibility when it comes to electronic payments. That credibility gap could impact industry expectations around the massive federal stimulus plan. Whether the forthcoming "meaningful use" EHR incentives will be paid as promised could be called into question.

Another issue on the EDI front worth noting is Minnesota's mandate, which became effective in three stages during 2009, to use electronic claims and related transactions (see story, this page).

The ICD-10 Challenge

With the coming deadline to migrate to the ICD-10 code sets, awareness is growing in the industry that preparations need to start in earnest this year.

"Payers are very aware of the deadlines," says Laurine Johnson, senior health information management consultant at Ingenix Consulting. "I see more payers getting prepared than providers."

It isn't that provider awareness is lacking, but more that they don't know how to get started, adds Watkins of Ingenix. Providers are intimidated with ICD-10 because they are starting to understand that the migration from ICD-9 encompasses so much of their business. "We get folks scratching their heads saying, 'How big is this? It feels big but I'm not sure.' After we educate them, they are overwhelmed."

Still, some providers continue to believe that ICD-10 is an information technology issue-their vendors simply need to increase data fields "and we're on our way," Johnson notes.

To start with, adoption of ICD-10 will affect nearly all information systems in an organization and many of its processes. The biggest impact, Watkins says, will be in such areas as clinical and financial documentation, billing, coding, and reimbursement contracts between providers and payers.

Physicians will have to document care to a far more granular level using ICD-10. That's why Watkins advises organizations to start getting clinicians this year to think about the terminology of the new code set. "Doctors don't document in codes, but in terminology," he says. So they need to change their terminology to be consistent and granular with ICD-10. "We're seeing some providers starting to analyze how to improve the documentation process," he adds.

The documentation challenge, Johnson notes, is even bigger for ICD-10 procedure codes because they are even more granular and anatomically involved than the diagnosis codes.

Where to Start?

In addition to preparing clinicians to document more comprehensively, providers during 2010 should inventory every information system to assess which ones use ICD-9, Johnson says. "That includes medical students using faculty-issued software, so you have to assess research areas."

Organizations also must assess the ICD-9 data they have-some of it decades old. They must decide how to maintain that data and for how long. "How much of it do you translate? Five years? Ten years?" Johnson asks. "If translated, how does that impact hardware and software and how do you do the translation?"

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