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October 2003
Volume 67 |
Number 10 |
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HIPAA Transactions Rule Deadline Looms
Karin Bierstein, J.D.
Assistant Director of Governmental Affairs (Regulatory)
Yes, the “Practice Management” column
does seem to be turning into the Health Insurance
Portability and Accountability Act (HIPAA) column.
We promise that other topics will continue to appear.
By now, the October 16 deadline for physician practices
to be submitting claims that comply with the HIPAA
standard for electronic transactions is at hand. At
press time, a very large number of anesthesiologists
were still testing their ability to transmit HIPAA-compliant
claims, and far too many health plans had yet to demonstrate
that they were fully prepared to process such claims.
Steps That ASA Members Should Still Consider
1. Eliminate the most obvious errors in
your HIPAA claims. Anesthesia groups,
practice management systems vendors, clearinghouses
and payers likely made much progress during September.
Still the industry anticipates that the transition
to the new claims standard, with all of its data content
and format changes, will not be complete for some
time. To minimize the potential for rejection, ASA
members and their billing managers should check the
list of common HIPAA errors in the accompanying box
against their own “production” claims.
(The list resulted from a multiclaim analysis by Claredi,
a firm specializing in HIPAA transactions testing
and certification services.)
Provider error number 12, invalid procedure codes,
raises the question of which Current Procedural Terminology™
code anesthesiologists should use: the surgical procedure
code or the anesthesia (0XXXX) code. There has been
some confusion over this issue. The Professional Claim
Standard, known as the “837,” requires
the 0XXXX code on all transactions. If the payer needs
the surgical code, that code must be supplied in addition
to the anesthesia code. In the language of the 837
Implementation Guide, the surgical code is “Required
on claims where anesthesiology claims are being billed/reported
if the provider knows the surgical code and knows
the adjudication of the claim will depend on provision
of the surgical code.”
Another problem reported by anesthesia practices that
have tested their HIPAA transactions is the missing
“provider taxonomy” code. These codes
identify the type, classification and specialization
of physicians and, like the surgical codes, are required
if known to affect adjudication of the claim. The
list is available at <www.wpc-edi.com>
(as is the 837 Implementation Guide itself).
2. Watch out for new fees charged by payers that route
claims through clearinghouses. One of
the unintended consequences of the HIPAA Transactions
and Code Sets Rule was the opportunity for owners
of clearinghouses to make themselves indispensable.
Billing system vendors have forced physicians to use
clearinghouses that were previously unnecessary —
and in which they now have ownership or contractual
interests. Anesthesia practices have reported new
per-claim costs of 38 cents and up associated with
the use of clearinghouses.
Health plans too have an apparent incentive to mandate
the submission of claims through clearinghouses, rather
than directly. The Centers for Medicare & Medicaid
Services (now CMS, then HCFA) addressed this concern
in the Final Rule on the electronic standards transaction,
stating that if a health plan operates as a clearinghouse
or requires the use of a clearinghouse, the provider
is not to be saddled with the incremental cost.
3. Your payer will not test or will not
pay HIPAA-compliant claims? File a complaint.
At a September meeting with representatives of several
medical specialty societies, Karen Trudel, Deputy
Director of CMS’ Office of HIPAA Standards,
made a plea for payer-specific information instead
of general unreadiness commentary. CMS may be able
to deal with individual payers (not just Medicare
carriers) that do not comply with the HIPAA Transactions
and Code Sets Rule. Indeed the agency indicated in
its July 24 Compliance Guidance (see
“Practice Management” column in August
2002 NEWSLETTER) that enforcement
would be complaint-driven. If any of your health plans
are not paying your claims and you have done all you
can to schedule or complete testing with them, file
a complaint at <www.cms.hhs.gov/hipaa/hipaa2/support/correspondence/complaint>.
If for any reason you would rather not identify yourself
to CMS, you might alternatively send your complaint
to the American Medical Association (AMA) using the
AMA/ASA Health Plan Complaint Form available in the
Members Only section of the ASA Web site at <www.ASAhq.org>.
In either case, please forward a copy of your complaint
to <mail@ASAwash.org>.
4. Take care of your cash flow needs; get or increase
a line of credit. Even if you are 100 percent
ready to submit HIPAA-compliant claims, some of your
health plans may not be. Cash flow interruptions remain
a significant possibility given the magnitude of the
industrywide changes. It should not be difficult to
obtain the protection of a line of credit.
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Common Data
Errors in HIPAA Claims
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| This list is provided
by Claredi to assist the industry in
its HIPAA compliance efforts. This generic
list reflects common provider errors
in the 837 Professional Claim Standard.
It does not reflect any one provider,
vendor or clearinghouse and is provided
only as an example of frequent errors.
Your particular experience may vary.
CLAREDI MAKES NO REPRESENTATION OR WARRANTY
OF ANY KIND. If you want to see your
particular errors, we suggest you test
your own HIPAA transaction files through
Claredi. An error list such as this
is only a general guidance and should
not be used in lieu of testing your
own transactions. For more information
on HIPAA transactions testing, visit
<www.claredi.com>.
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Provider error
#1
# Missing or incomplete Service
Facility Name, Address and I.D.
(for services rendered outside
of the office or home)
# Invalid Service Facility ZIP
code or State abbreviation
Provider error
#2
# Missing Medicare Assignment
indicator and/or Benefits Assignment
indicator
Provider error
#3
# Invalid Provider UPIN (Rendering
provider, referring provider,
etc.)
Provider error
#4
# Missing Referring Provider
I.D. or complete name of Referring
Provider
Provider error
#5
# Missing or invalid Subscriber’s
birth date
Provider error
#6
# Missing “Insurance
Type Code” for secondary
coverage
# The secondary coverage information
(e.g., Spouse’s payer)
is important in order to file
not only secondary claims but
also primary claims
Provider error
#7
# Missing Payer Name and/or
payer I.D.
# This is required for both
primary and secondary payers
in all claims
Provider error
#8
# Missing or invalid Admission
Date for Inpatient services
Provider error
#9
# Missing or incomplete Ordering
Provider Name, Address and Identifier
Provider error
#10
# Missing “Attachment
Transmission Code” on
claims with attachments
Provider error
#11
# Incomplete “Other
Payer” information. This
is required in all secondary
claims and in all primary claims
that will involve a secondary
payer. (Possibly this is one
of the most disruptive missing
data clusters. It does not appear
higher on the list because not
all claims involve a secondary
payer.)
Provider error
#12
# Invalid procedure code.
Watch out for “made up”
codes!
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©
2003 Claredi. All Rights Reserved. |
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