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2010 UBO/UBU Conference Title: Bill Spawning – HIPAA 837I and 837P Session: T-6-1100.

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Presentation on theme: "2010 UBO/UBU Conference Title: Bill Spawning – HIPAA 837I and 837P Session: T-6-1100."— Presentation transcript:

1 2010 UBO/UBU Conference Title: Bill Spawning – HIPAA 837I and 837P Session: T

2 Objectives Have a high level awareness – of the HIPAA 837I standard transaction, to include being able to understand the concept of a data segment and a data element – of what will be available in the Central Billing Events Repository – of those financial elements that will be available in the Service Enterprise Resource Planning System (such as General Fund Enterprise Business System, or GFEBS) Understand that billing is much more than coding (and that getting a bill in the mail is less than half the work of getting the money in the “bank”) 2

3 Pre-Test Raise your hand as I read the statements if the statement applies to you. 1. I’ve written computer programs such as “Grand Theft Auto” – it was a piece of cake and only took 2 million hours of detailed programming 2. All programs I’ve ever used had the same password requirements; – no special characters; – with special characters but only the !&()+*-?= ; – with special characters but 3. When doing my taxes, I have ALWAYS had all the information they wanted. It has ALWAYS been called the same thing on the W2 as on the tax form. 3

4 What You Need to Learn Prior to Falling Asleep The MHS does not collect some data needed for certain types of billing, and never will. – It is not cost effective. – The data would not be used by anyone else. – Get over it. There is a lot of power in the HIPAA 837 electronic bill capability to do coordination of benefits, enter co-pay/ deductibles, and other civilian things. 4

5 Standard HIPAA 837 I Think of submitting your individual taxes [HIPAA 837I] – Must be submitted with correct data in correct blanks – Taxpayer [Patient] name and demographic information – Earnings by W2 [rates for each CPT] – Deductions [co-pay, deductible] – What if you don’t have the information? – Which sections can you just skip? Farm subsidies [type of currency] – How much does the Federal government [insurance company] owe you? 5

6 HIPAA 837 I Transmission Control Communications Transport Protocol – Address of the entity sending the transmission and the address of the entity receiving the transmission – Example: Sent by central AF billing to a clearing house – Addresses are those the two parties agree upon Matched as second to end of entire transmission by a “Communications Transport Trailer” 6

7 HIPAA 837I Transmission Control Interchange Control Header – Provides the security information, such as a password or other identifying information – Date and time of interchange – Which repetition separator will be used – Interchange version number – Interchange control number – If an interchange acknowledgement is needed – If this is a test or production data Matched as second to end of entire transmission by a “Interface Control Trailer” 7

8 Transmission Control Functional Group Header and at the end Trailer – Says what kind of transaction, such as 837I, 837P, HIPAA Health Care Claim (Professional, Institutional, Dental) HIPAA Health Care Claim Payment/Advice Transaction HIPAA Benefit Enrollment and Maintenance HIPAA Health Care Eligibility/Benefit Inquiry HIPAA Health Care Eligibility/Benefit Response HIPAA Health Care Claim Status Request HIPAA Health Care Claim Status Notification HIPAA Health Care Review Information HIPAA NCPDP DO – Retail Pharmacy 8

9 How Does The OUTSIDE Fit Together? Detail Segment – 837P 9 Communications Transport Trailer Interchange Control Header Functional Group Header Detail Segment – 837I Detail Segment – 276 Functional Group Trailer Functional Group Header Functional Group Trailer Functional Group Header Functional Group Trailer Interchange Control Trailer Communications Transport Protocol

10 Detail Segments HIPAA Health Care Claim – Institutional – Professional – Dental HIPAA Health Care Claim Payment/Advice Transaction HIPAA Benefit Enrollment and Maintenance HIPAA Health Care Eligibility/Benefit Inquiry HIPAA Health Care Eligibility/Benefit Response HIPAA Health Care Claim Status Request HIPAA Health Care Claim Status Notification HIPAA Health Care Review Information HIPAA NCPDP DO – Retail Pharmacy 10

11 Basic “Penmanship” Rules BASIC A_Z (upper case) 0…9 (Arabic #s) – ! & () + *, -. / : ; ? = space Extended a-z (lower case) – % [ ] _ { } \ # $ Data element separator, asterisk (*) Sub-element separator, colon (:) Segment terminator, tilde (~) If transmitting in USA, usually extended set is fine – could be problems with international partners, particularly with foreign languages For the rest of this briefing, all the lower case letters should be upper case, but are lower so you can read them more easily 11

12 1000 Header HEADER ST*837* *00510X223~ Begin hierarchical transaction – BHT*0019*00*0123* *0932*CH~ – BHT – Beginning of hierarchical transaction – “0019” – Information Source, Subscriber, Dependent – “00” – original transmission (not sent to receiver before) – 0123 – submitter’s batch control number – – date of transmission in CCYYMMDD – 0932 – time in HHMM, so 9:32 am – “CH” – chargeable 12

13 1000A Submitter – NM1*41*2*AF Central Billing*****46* ~ NM1 – a name element “41” means submitter “2” means non-person entity Last name **** means I’m not using a bunch of fields, in this case the first name, middle name, prefix, suffix “46” means Electronic Transmitter Identification Number “ ” – our address – PER*IC*Fred Darcy*TE* ~ PER – submitter EDI contact information “IC” means Information Contact Fred Darcy is the free-form name “TE” means telephone and then the number 13

14 1000B Receiver – NM1*40*2*AF Clearing House*****46* ~ NM1 – a name element “40” means RECEIVER “2” means non-person entity Last name **** means I’m not using a bunch of fields, in this case the first name, middle name, prefix, suffix “46” means Electronic Transmitter Identification Number “ ” – address for where we are sending the package 14

15 2000A Billing – Hierarchical and Billing Provider HL – Billing Provider Hierarchical Level – HL*1**20*1~ notice this is the 1 st “HL” 2000A Billing Provider Specialty – PRV*BI*PXC*261QM1100X~ PRV – Billing Provider Specialty Information segment “BI” means billing “PXC” means health care provider taxonomy code the HIPAA Health Care Provider Taxonomy 15

16 2000A Foreign Currency Information Situational – This will not be in the Central Billing Events Repository and probably will not be used by the billing organization Used to specify the currency (e.g., Euro, pounds UK, dollars Canadian) used in the transaction CUR*85*CAD~ – CUR means Currency – “85” means billing provider – “CAD” means Canada (CA is Canada, D is dollar) 16

17 2010AA Billing Provider Name NMI*85*2*56th Medical Group Luke*****XX* ~ – NM1 – segment name – “85” means billing – “2” means non-person entity – 56th Medical Group Luke – last name – ***** not used first name, middle name, prefix, suffix – “XX” National Provider Identifier – – NPI for Luke N3*7219 North Litchfield Road~ N4*Luke AFB*AZ*85309~ 17

18 2010AA Billing Provider Name REF*EI*as if I can even guess~ – REF – billing provider tax ID – “EI” – employer tax number – Spot for the number PER*IC*Dane I-forget* *ex*56~ – PER – billing provider contact info segment, situational, if different from submitting info – “IC” means information contact 18

19 2010AA Billing, Pay-to Address NM1*87*2~ – “87” means “Pay-to provider” * N3*5109 Leesburg Parkway*Suite 701*~ – N3 is the address segment detail code * – Address line – Second address line N4*Falls Church*VA*22041~ – N4 is a city/state/zip segment detail – City – State – Zip 19

20 2000B Subscriber Loops 2000B Subscriber HL Loop HL*2*1*22*0~ – notice this is the 2 nd “HL” in the ST segment * – the HL loop to which this one is subordinate * – 22 means “subscriber” * – 0 means the subscriber is the patient and this is the only claim 20

21 Central Billing Events Repository Data Start HERE 21

22 2000B Subscriber Loops 2010BA Subscriber – SBR*P*18*GRP ******CI~ 2010BA Subscriber name – NM1*IL*1*Doe*John*T**Jr*MI*123456~ – N3*123 Main Street~ – N4*Phoenix*AZ*85309~ – DMG*D8* *M~ – REF*SY* ~ (subscriber 2 nd ID {SY is “SSAN is next”}, situational, not required) 22

23 2000B Subscriber Payer Loops 2010BB Payer Name NM1*PR*2*Health Inc Insurance*****PI*1234~ – PR is payer – PI is payer identification N3*123 Main Street~ N4*Phoenix*AZ*85309~ REF*FY*1234~ (Reference – Payer 2 nd ID, situational, not required) – FY means “claim office number” REF*G2*1234~ (Reference – Billing Provider 2 nd ID, situational, not required) – G2 means provider commercial number 23

24 2000C Patient Loops 2000C Patient HL Loop – HL*3*2*23*0~ – PAT*01~ 01 is a spouse – NM1*QC*1*Doe*Sally*J~ QC is that this person is the patient – N3*123 Main Street – N4*Phoenix*AZ*85309 – DMG*D8* *F~ In the patient demographic segment, the date is the birth date F means female 24

25 2300 Claim – Diagnoses! 2310A Attending Provider 2310B Operating Physician 2310C Other Operating Physician 2310D Rendering Provider 2310E Service Facility Location 2320 Other Subscriber Information 2330A Other Subscriber Name 25

26 2300 Claim Information CLM*0009OUT *500***11:A:1*Y*A*Y*I~ – 0009OUT (DMIS ID 0009; outpatient;1 Mar 2010; 111 th claim) is an example of a Claim Submitter’s identification of this claim, it is the patient control number, the number used to track this claim through the biller’s system – 500 is an example of the total amount of all submitted charges of service segments for this claim; this number must match the sum of all the SV2 segments 26

27 2300 Claim Information CLM*0009OUT *500***11:A:1*Y*A*Y*I~ – 11 is an example of a Facility Code Value (think Place of Service, in this case 11 is the doctor’s office) – A is the facility code qualifier for the Uniform Billing Claim Form Bill Type – 1 is the frequency of the claim (the only bill for the encounter, it covers the entire encounter) – “Y” is there for entertainment value and to confuse people, the guidance says “not used” but the example shows it – “A” the provider accepts assignment from the payer – “Y” means the patient has assigned benefits to the provider – “I” means federal law permits release of diagnosis info 27

28 2300 Claim Information DTP – Date or Time or Period – DTP*096*TM*1130~ DTP – Date or time or period “096” means “discharge” “TM” means the time will be expressed in Format HHMM 1130 is an example of 11:30 am – DTP*434*RD8* ~ DTP – Date or time or period “434” means “statement” “RD8” means time will be CCYYMMDD-CCYYMMDD means 1 Mar 11-5 Mar 11 28

29 2300 Claim Information DTP – Date or Time or Period – DTP*435*DT* ~ DTP – Date or time or period “435” means “admission” “DT” means the time will be expressed in Format CCYYMDDHHMM is an example of 1 Mar :42 pm 29

30 2300 Claim Information CL1 – Institutional Claim Code CL1*1*7*30~ – CL1 – institutional claim code – 1 – an admission type code (1 = emergent; 2 = urgent; 3 = elective; 4 = newborn) – 7 – an admission source code (7 = ER; 2 = clinic; 1=nonhealthcare facility point of origin) – 30 – a patient status code (see list at end of briefing) REF*LU*MD~ – REF is a Reference identification qualifier – LU is location number for an auto accident state or province code REF*EA*4444MN~ – EA is a medical record identification number 30

31 2300 Claim Information HI – Diagnosis information – HI*ABK:T8731*Y~ “ABK” is ICD-10-CM principal diagnosis “BK” is ICD-9-CM principal diagnosis T8731 is the diagnosis for neuroma of amputation stump, right upper extremity Y” is “yes” in the Present on Admission Indicator – HI*ABJ:T8741*Y~ “ABJ” is ICD-10-CM admitting diagnosis “BJ” is ICD-9-CM admitting diagnosis T8731 is the diagnosis for neuroma of amputation stump, right upper extremity – HI*APR:R110~ “APR” is ICD-10-CM reason for outpatient visit 31

32 2300 Claim Information HI – HI*ABN*T560X1*Y*ABN*W3301*Y~ “ABN” is ICD-10-CM external cause of injury T560X1 is Toxic effect of lead and its compounds, accidental “Y” is yes for the Present on Admission Indicator “ABN” is for the additional ICD-10-CM external cause of injury W3301 is Accidental discharge of shotgun “Y” is yes for the POA indicator – HI*DR:123~ “DR” is diagnosis related group – HI*ABF:J151*Y~ “ABF” is ICD-10-CM other diagnosis 32

33 2300 Claim Information HI*BBR:0B110F4:D8: ~ – “BBR” is the ICD-10-PCS principal procedure – 0B110F4 is Tracheostomy device inserted to trachea, open, to outside (cutaneous) – D8 is that a date in the CCYYMMDD format follows HI*BBQ:02130KF:D8: *BBQ:4A023N8:D8: ~ – BBQ is other ICD-10-PCS procedures – D8 is that a date in the CCYYMMDD format follows 33

34 2300 Claim Information NOT in CBER Segments that are available but would not be in the Central Billing Events Repository PWK – Claim supplemental information (paperwork) AMT – Patient estimated amount due REF – Service authorization exception code (for example if it was an emergency which is why there was no pre-authorization REF – Referral number (for example a payer provided a referral number for so many physical therapy encounters) 34

35 2300 Claim Information NOT in CBER Segments that are available but would not be in the Central Billing Events Repository REF – Prior authorization (for example for major surgery) REF – Investigational device exemption number REF – Demonstration Project Identifier REF – Peer Review Organization Approval Number NTE – Claim note or a Billing Note (used when the provider wants to indicate there is additional information needed to substantiate medical treatment) 35

36 2300 Claim Information NOT in CBER Segments that are available but would not be in the Central Billing Events Repository HI*BI – Occurrence span information HI*BH – Occurrence information HI*BE – Value information HI*BG – Condition information HI*TC – Treatment code condition (used for home health agencies) 36

37 2310A Attending Provider Name NM1*71*Jones*John****XX* ~ – “71” in this position is “attending physician” – XX is “the NPI is next” PRV*AT*PXC*208D00000X~ – PRV is attending provider specialty segment – “AT” is attending – “PXC” is “the HIPAA Health Care Provider Taxonomy is next” 37

38 2310 Additional Providers 2310B NM1*72*1*Meyers*Jane*****XX* ~ – “72” is operating physician – XX is “the NPI is next” – Is only used if there is a surgical procedure on the claim 2310C NM1*ZZ*1*Doe*John*A***XX* ~ – “ZZ” is mutually defined to indicate “other operating physician” – Usually not needed, usually only one surgeon 2310D NM1*82*1*Doe*Jane*C***XX* ~ – “82” is rendering provider 38

39 2310E Service Facility 2310E NM1*77*2*Bolling Clinic*****XX* ~ – “77” is Service Location (other than the doctor’s office) – “2” is non-person entity N3*1300 Angell Street~ N4*Bolling AFB*DC*20032~ 39

40 2310F Referring Provider NOT in CBER NOT in the Central Billing Event Repository, but could be for civilian sector NM1*DN*1*Welby*Marcus*W**Jr*XX* ~ – “DN” is referring provider – “1” is a person – XX is “the NPI is next” 40

41 2320 Other Subscriber Information SBR*S*01*GR00786******13~ – SBR is a subscriber information segment – “S” is secondary coverage – “01” is that the spouse is the one with the coverage – “GR00786” is an example of a insured group or policy number – “13” is a claim filing indicator code representing “point of service” – eventually this will go away when HIPAA National Plan IDs are fielded 41

42 Claim Adjustments, Repricing…NOT in CBER Claim adjustments, repricing, coordination of benefits (COB) payer paid amount, remaining patient liability, adjudication information, check remittance date, and other post bill generation activities will not appear in the Central Billing Events Repository (CBER). – These activities will be done by the Service billing/collections activity. – Collections, adjustments, repricing, co-pays, deductibles etc., will be tracked in the Service Enterprise Resource Planning (ERP) system. 42

43 2330B Other Payer Name NM1*PR*2*Another Insurance Group*****PI* ~ – “PR” is payer – “2” is non-person entity – “PI” is payer identification N3*100 N Broadway*Suite 10B~ N4*New York City*NY*10008~ Other payer information such as provider name, operating physician and service facility will not be in the CBER as these data elements are not collected and stored centrally 43

44 2400 Loops 2400 Service Line 2420C Rendering Provider 2420D Referring Provider 44

45 2400 Services Provided LX*1~ – LX is a service line number segment SV2*0300*HC:81099*73.42*UN*1~ – SV2 is a institutional service line segment – 0300 is an example of a revenue code for the laboratory – “HC” is a HCPCS code (includes CPT) – “81099” is a HCPCS lab unspecified code – “73.42” is the price billed – “UN” is “unit” – “1” is a quantity 45

46 2400 DTP*472*D8* ~ – DTP is date or time or period segment – “472” is a service – D8 indicates date format will be CCYYMMDD – is 2 Mar 11 46

47 Transaction Set Trailer NOT in CBER Would not be in the CBER, this is done when the HIPAA transaction is sent to the clearing house SE*1230* ~ – SE is a transaction set trailer – 1230 is the number of segments included in the transaction including ST and SE segments – is the same transaction set control number in the ST02 that began the transaction 47

48 Transaction Set Trailer NOT in CBER Again, this would not be in the Central Billing Events Repository – it is something used by the billing organization to make sure the “box of bills” are sent to the correct clearing house (e.g., FedEx) Then the clearing house re-directs the data to the payer 48

49 Business Usage Coordination of Benefits – The CBER will list all the known possible payers based on what is in the Other Health Insurance file and the PATCAT (patient category, such as Coast Guard) – Billing entity needs to determine when there is a primary and secondary payer, will the bill go to The first payer who enters what he paid, and the first payer send it directly to the second payer The first payer send back his remittance, then you need to enter the 1 st payer’s input and send to the second payer 49

50 Capturing The Data Encounter Data – Patient Registration At the MTF entering the patient initially in the CHCS registration module will “bring down” the patient data (e.g., birthday, gender, EDI-PN) from DEERs – Appointment Module To make an appointment there must be a “file and table build” where the provider data (e.g., NPI and HIPAA taxonomy) are stored Also will collect the date/time of the scheduled appointment and the DMIS ID – Inpatient Module Assigns the medical record number, links the provider file information 50

51 Capturing The Data Encounter Data – Ambulatory Data Module Where outpatient coded data are collected – Can come from AHLTA or be entered directly in ADM – Coding Compliance Editor Where all inpatient coded data are entered Patient Demographics – DEERS Insurance Information – DEERS Standard Insurance Tables/Other Health Insurance – PATCAT – patient categories 51

52 Capturing The Data Rates – Insurance and Interagency Inpatient – Diagnosis related group based Place of service 11 – outpatient doctor’s office professional Place of service 23 – hospital emergency room institutional Place of service 22 – outpatient hospital (same day surgery institutional) Ambulance Laboratory Diagnostic Imaging Pharmaceutical Dental Anesthesia – To Patient Cosmetic Family member inpatient rate 52

53 MHS Limitations Do not collect a separate institutional encounter for outpatient services done somewhere other than the doctor’s office – APVs, Observation, Emergency Department Do not collect anesthesia minutes of service Do not collect the venipunctures (collection of specimen in the laboratory) Do not collect ambulance mileage 53

54 MHS Limitations Do not have standardized dental encounter data information (each Service has own collection system which does not feed data centrally) Not all laboratory services are collected in CHCS – CoPath Do not collect the exact pharmaceutical dispensed Coding – Do not collect if it is workers’ compensation and many other issues (condition, occurrence, and value codes) 54

55 MHS Limitations Poor understanding of assignment of PATCATs – BASED ON ELIGIBILITY OF THAT CARE ON THAT DATE No “incident to” concept – encounters are collected based on the individual who did the service, not in the name of the physician – Otherwise, physician assistants and nurse practitioners could not treat new problems – they could only see “follow-up” patients and do services already ordered by physicians Possible suboptimal pursuit of Other Health Insurance In some cases, limited staffing to do accounts receivable 55

56 MHS Limitations Need to receive daily CHCS Provider File update – no central repository with every provider NPI type I Do not have patient level cost accounting – Do not have standard Revenue Codes – MEPRS is non-standard and inconsistent (e.g., code where work is done, but physical therapy is done on the wards) – Cannot do DRG cost outliers 56

57 Objectives Have a high level awareness – of the HIPAA 837I standard transaction, to include being able to understand the concept of a data segment and a data element – of what will be available in the Central Billing Events Repository – of those financial elements which will be available in the Service Enterprise Resource Planning System (such as General Fund Enterprise Business System, or GFEBS) Understand that billing is much more than coding (and that getting a bill in the mail is less than half the work of getting the money in the “bank”) 57

58 Questions Is it time to wake up now? Yes. Where am I? The same place you were when you fell asleep. Is this Kansas? Don’t you wish. 58

59 Patient Status Examples: Required. (For all Part A inpatient, SNF, hospice, home health agency (HHA) and outpatient hospital services.) This code indicates the patient’s status as of the “Through” date of the billing period (FL 6). Code/Structure 01Discharged to home or self care (routine discharge) 02Discharged/transferred to a short-term general hospital for inpatient care. 03Discharged/transferred to SNF with Medicare certification in anticipation of covered skilled care (effective 2/23/05). See Code 61 below. 04Discharged/transferred to an Intermediate Care Facility (ICF) 05Discharged/transferred to another type of institution not defined elsewhere in this code list (effective 2/23/05). Usage Note: Cancer hospitals excluded from Medicare PPS and children’s hospitals are examples of such other types of institutions. Definition Change Effective 4/1/08: Discharged/Transferred to a Designated Cancer Center or Children’s Hospital. 06Discharged/transferred to home under care of organized home health service organization in anticipation of covered skills care (effective 2/23/05). 07Left against medical advice or discontinued care 08Reserved for National Assignment *09Admitted as an inpatient to this hospital 59

60 Patient Status Examples: 10-19Reserved for National Assignment 20Expired (or did not recover - Religious Non Medical Health Care Patient) 21Discharged/transferred to Court/Law Enforcement 22-29Reserved for National Assignment 30Still patient or expected to return for outpatient services 31-39Reserved for National Assignment 40Expired at home (Hospice claims only) 41Expired in a medical facility, such as a hospital, SNF, ICF or freestanding hospice (Hospice claims only) 42Expired - place unknown (Hospice claims only) 43Discharged/transferred to a federal health care facility. (effective 10/1/03) Usage note: Discharges and transfers to a government operated health care facility such as a Department of Defense hospital, a Veteran’s Administration (VA) hospital or VA hospital or a VA nursing facility. To be used whenever the destination at discharge is a federal health care facility, whether the patient lives there or not Reserved for national assignment 50Discharged/transferred to Hospice - home 51Discharged/transferred to Hospice - medical facility 52-60Reserved for national assignment 60

61 Patient Status Examples: 61Discharged/transferred within this institution to a hospital based Medicare approved swing bed. 62Discharged/transferred to an inpatient rehabilitation facility including distinct part units of a hospital 63Discharged/transferred to long term care hospitals 64Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare 65Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital. 66Discharged/transferred to a Critical Access Hospital (CAH). (effective 1/1/06) 67-69Reserved for national assignment 70Discharge/transfer to another type of health care institution not defined elsewhere in the code list. (effective 4/1/08) 71-99Reserved for national assignment *In situations where a patient is admitted before midnight of the third day following the day of an outpatient diagnostic service or service related to the reason for the admission, the outpatient services are considered inpatient. Therefore, code 09 would apply only to services that began longer than 3 days earlier or were unrelated to the reason for admission, such as observation following outpatient surgery, which results in admission 61


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