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.

What needs to be done to be ready?

• The compliance date for the HIPAA 5010 transaction sets for claims and related transactions is January 1, 2012.
• 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 need to analyze the affect of the changeover on business processes, and talk with vendors and insurers about their schedules for internal mediation and external testing.

Most providers believe that their vendor and clearinghouse will take care of them during this transition. That is a scary spot for providers to be in though if they are not aligned with a vendor and clearinghouse agile enough to handle all of this confusion. Providers also need to know that most of the changes in the adoption of 5010 will have to do with business processes such as providing more benefit information on insurance eligibility responses and better support for automated posting of remittance advice. These are not just IT problems for the vendors and clearinghouses to handle so the changeover will require a large time commitment from providers.

The ICD-10 Challenge
A transition from the three-decade-old ICD-9 diagnosis and procedure code sets to the vastly expanded ICD-10 code sets has a deadline of October 2013. 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, payers, and observers need to start serious work on ICD-10 migration during 2010. Adoption of ICD-10 will affect nearly all information systems in an organization and many of its processes. The largest impact 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, so providers will need to improve the documentation process.

How should providers begin?

• Prepare clinicians to document more comprehensively
• Inventory every information system to assess which ones use ICD-9
• Decide how to maintain legacy ICD-9 data and for how long.
• Assess how migrating to ICD-10 will affect increasing use of data analysis technology.
• Create awareness and educate all in the organization this year
• Do not bank on a further delay in ICD-10's deadline, which previously was extended by two years. The Centers for Medicare and Medicaid Services last March made clear it believes the Oct. 2013 compliance date is achievable.

Potential Medicare coding problem could affect bonus payments
When e-prescribing office visits, office consults, mental health services, diabetic self-management training, and pelvic and breast exams; the use of three specific "G codes," could cause some confusion. If an electronic prescription was generated, or simply attempted, a G code is put in a field on the claim for services to document the use of e-prescribing. The first code reports a qualified e-prescribing system was used for all prescriptions during the visit, a second code applies if a qualified system was available but no prescriptions were generated during the visit and a third code is used to indicate an electronic prescription could not be generated because of legal prohibitions, or other reasons. So, all three codes count toward getting an e-prescribing incentive payment even if an electronic prescription was not transmitted or even written. Along with the appropriate G code, the claim also must have a dollar value for the G code placed in a specific field. But G codes aren't diagnostic or procedure codes so they don't have dollar values. Putting a $.01 in the field solves the problem but many prescribers don't know to do it and many claims clearinghouses aren't checking for it. The remittance advice for all claims properly generated and processed with the G code show that the code was denied, possibly causing providers to believe that all the claims that document they properly e-prescribed, or tried to, won't qualify for a bonus payment.

CMS' Response is that the G code is being denied for payment because it is a quality data code, but the remittance advice also should include a specific code-N365-that indicates the G code was received and recognized by CMS. It's that code that providers should be looking for on their remittance advice. Successful electronic prescribing participants will get their 2009 incentive bonus-on all Medicare-covered Part B charges and not just charges for specific services where they reported a quality data code-in a lump sum payment during 2010. In 2010, a provider only has to have a required system and report one G code indicating that they electronically prescribed (and put in a $.01 value), for a total of 25 appropriate office visits or services to get the 2% bonus payment. Eligible providers also must have at least 10% of their total Medicare Part B charges comprised of CPT codes for appropriate visits or services, a requirement that has not changed from 2009. Group practices also can participate and earn an incentive payment equal to 2% of the practice's total estimated Medicare Part B allowed charges. Medicare will accept e-prescribing reporting via qualified registries-intermediary organizations that collect and report data-and electronic health records systems.

Finding the Core to Standardization
The goal of CORE is to reach industry consensus on transaction sets that will enable health care electronic data interchange transactions to be conducted as easily as an ATM transaction. CORE started with Phase I of an electronic eligibility/benefit determination transaction. The recently completed Phase II of CORE further tightened the eligibility/benefit determination transaction and included claims status. Participants now are developing prior authorization and remittance transactions in Phase III.

Source: Health Data Management Magazine, 02/01/2010