Source of Payment Typology Code: Status Report PHDSC Business Meeting October 2, 2007 Amy Bernstein and Judy Parlato, co-chairs Public Health Data Standards Consortium, Payer Type Workgroup

Topics Brief overview/reminder Relationship to national standards Status of Pilot projects Maintenance activities

Use of Payer Typology Payer Type codes are defined as up to six left-justified alpha numeric characters. Each character from the left to the right represents a new hierarchical level in the value set. The typology is loosely modeled on the ICD classification system for disease, which codes to the most specific disease possible.

Use of Payer Typology The first digit of each code is the organization that provides the funds for the care; Additional digits provide more information about the specifics of the plan or mechanism through which these funds are provided.

Major Payor Codes Medicare Medicaid Other Government ( not Medicare, Medicaid or corrections) Department of Corrections Private Health Insurance Blue Cross/Blue Shield Managed Care, unspecified (*) No payment from organization Miscellaneous/other

Example of second- and third-digit codes 1MEDICARE 11 Medicare (Managed Care) 111 Medicare HMO 112 Medicare PPO 113 Medicare POS 119 Medicare Managed Care Other 12 Medicare (Non-managed Care) 121 Medicare FFS 122 Medicare Drug Benefit 123 Medicare Medical Savings Account (MSA) 129 Medicare Non-managed Care Other 19 Medicare Other

Example of second- and third-digit codes 8NOPAYMENT from an Organization/Agency/Program/Private Payor Listed 81 Self-pay 82 No Charge 821 Charity 822 Professional Courtesy 823 Research/Clinical Trial 83 Refusal to Pay/Bad Debt 84 Hill Burton Free Care 85 Research/Donor 89 No Payment, Other

Available Documentation The Payer Typology – The complete hierarchical list of payer categories The Payer Typology User Guide & click on Users Guide for Source of Payment Typology Payer Category definitions and relevant standards information Public Health Data Standards Consortium Payer Work Group Group responsible for development and maintenance of Payer Typology

Relationship to National Standards Mandatory implementation of Payer Typology will depend on when support for reporting this code set included in ANSI X12 implementation guides, which for HIPAA guides could be many years down the road. Voluntary implementation of the Payer Typology will be incorporated into the next version of the Health Care Service Data Reporting Guide OR may be included in a host of other reporting vehicles, such as NCHS surveys, using existing formats.

Relationship to National Standards Currently Data Maintenance in progress to reference the typology in the ANSI X12 standards within the 837 transaction. It is anticipated that 5050 and beyond versions of the Health Care Service Data Reporting Guide will support the reporting of the Payer Typology. Current versions of 837 implementation guides could support reporting of the Payer Typology Code in the K3 segment with approval of the ANSI X12N Health Claims Work Group (TG2 WG2)

Relationship to National Standards: Progress We have obtained approval at the X12N, Task Group and Work Group levels. Notification received yesterday (October 1, 2007): Our DM was approved for publication by the PRB. The references to the Source of Payment Typology Code will be included as part of the 5050 (to be published in December 2007).

Status of Pilots--Georgia State of Georgia Implementation of Payer Typology hierarchies by January 2008 for all Georgia discharges for calendar year Georgia hospitals will be given an opportunity to stage the reporting of Payer Typology categories between now and next year. NOTE: Georgia is implementing three (3) hierarchical levels of full Payer Typology, which currently provides granularity to five (5) hierarchical levels.

Georgia Implementation Example-- continued Below is an example from the Georgia Pilot on the advantage of the Payer Typology over the previous payer type code structure Old Code Structure had ONE code for Self Pay The Georgia Implementation of Payer Typology has increased granularity to significantly improve reporting capabilities.

Georgia Implementation of Non- Payment Categories Replacing Single Self Pay Code 81Self Pay 82 No Charge 821Charity 822Professional Courtesy 823Research / Clinical Trial 83Refusal to Pay / Bad Debt 84Hill Burton Free Care 85Research / Donor 86No Payment Other

Status of Pilots--California State of California Deficiencies of all current payer type code sets have been identified. Staged migration plane for their inpatient collection system to use ANSI X and UB-04. Establish an electronic connection between the State and providers Migrate legacy system to use standard data content Anticipated that the Payer Typology will replace their legacy code system with migration to ANSI 837 and UB- 04 data content

Status of Pilots--Massachusetts State of Massachusetts The proprietary payer type code list used by the State of Massachusetts is problematic. The state data agency is planning to solicit the hospital feedback during calendar year 2007 on the merits or deficiencies of the Payer Typology as a replacement to their current proprietary payer type classification list.

Maintenance Activities The Source of Payment Typology is maintained by the National Center for Health Statistics / Centers for Disease Control and Prevention. Requests to change typology should be directed to the Payer Type Subcommittee of the Data Standards Committee of the Public Health Data Standards Consortium.

Maintenance Activities Changes to the Source of Payment Typology are made bi-annually in October and April. Any interested industry representative can make recommendations for additions or modifications by sending their comments via to Michelle Williamson These recommendations would be voted on by members of the Payer Type Subcommittee for possible inclusion in the Source of Payment Typology Code.