Transactions & Code Sets - Regional Initiatives
Correct Coding Initiative
Status Report submitted by:
Luisa DiIeso, MS, RHIA, CCS - CCI Subcommittee Chair
August 2003
Description: The Correct Coding Initiative is a joint endeavor of the following parties: Massachusetts Health Information Management Association (MHIMA), Massachusetts Health Data Consortium, and Health Insurance Payer Community
Committee Membership: A cross-section of MHIMA representatives by coding specialty (i.e. acute care, home care, physician practice, mental health) as well as HIPAA representatives from payer groups within the state and the Consortium representatives.
Committee Goals:
- Share Resources and Best Practices for Data Quality and HIPAA Transaction Code Set Compliance
- Highlight Data and Coding Discrepancies - Variations from Official Code Set Guidelines
- Solicit Input from the Payer Community for Future Educational Sessions
- Distribute Official Code Set Companion Guide for Payer Healthcare and Diagnostic and Procedural Data Quality
- Foster Productive Payer-Provider Relations
Committee Highlights: CCI established a calendar of agenda items for review from November of 1992 until April of 2003. Specific examples from the top five coding and data variation categories were reviewed by the committee and include the following:
Agenda Item |
HIPAA Code Set |
Key Issues Identified |
Official Guidelines |
V Codes
Categories of Data:
V76;V67;V57;V72 |
ICD-9-CM |
Sequencing GuidelinesPayer Information Systems - Non-Compliance with UB-92/Code Set Criteria |
ICD-9-CM Code Set Conventions
Coding Clinic Guidelines - AHA Official Code Set Resource |
Modifiers Hospital & Physician Practice
Examples:
-50-Bilateral
-52-Red. Svcs.
-59-Distinct Svc.
-76/-77-Repeat Procedures |
CPT-4 - AMA |
Payer Information Systems Issues- Variations in Accepting ModifiersPayer Interpretations - Contrary to Official CPT Code Set GuidelinesTraining Issues-Prov. |
CPT-4 - AMA Code Set Conventions
CPT Assistant - AMA Official Code Set Resource |
Mental Health Disorders
Categories of Examples:
292; 293; 310.2; 298; 315-319 |
ICD-9-CM |
Treatment-Location Payer Edits
Payer Requirements for a non-HIPAA Code Set (DSM-IV) |
HIPAA Code Set Transaction Regulations
ICD-9-CM Code Set Conventions
Coding Clinic Guidelines - AHA Official Code Set Resource |
Evaluation & Mgt. Services
Categories of Examples:
99251-99275 |
CPT-4 - AMA |
Definitions - Consults vs. Referrals
Combinations of E&M Service Codes - Payer Variations
Payer Communication |
CPT-4-AMA Code Set Conventions
CPT Assistant - AMA Official Code Set Resource |
Miscellaneous/Payer Issues
Examples:
Unlisted CPT Codes
Service Edits
Point of Service Edits
Referral Issues
Duplicate Claims |
CPT-4-AMA |
Provider Training Issues - Physician Practice
Lack of Provider - Point of Service Edits/ Information Systems Issues |
CPT-4-AMA Code Set Conventions
Payer Billing Manuals |
Conclusion: Payers who routinely attended the meetings (Fallon Health, Neighborhood Health Plan, Health New England, BMC, BCBSMA, CMS-Medicare, BMCHP) felt that sharing resources and examples of discrepancies was beneficial as they plan for HIPAA code set compliance and were well aware of official resources and guidelines for key agenda items. However, some key payers did not attend meetings regularly and it was difficult to gauge their status regarding HIPAA code set compliance.
Key Issues Identified: Information Systems; Training Issues (Focus - Physician Practice Providers); Need for Improved Communications - Payer-Provider; Provider-Provider (Health Information Management Personnel and Patient Accounts Personnel)
Future Goals: CCI will meet quarterly in order to continue to share best practices and information regarding updated resources and HIPAA code set regulations. In addition, the group would like to facilitate training and awareness programs geared toward official HIPAA Code Set Guidelines and updates. The agenda for next year will be set based on recommendations from the Operations Forum at Massachusetts Health Data Consortium and input from standing CCI committee members. Summary Information to be shared with the leadership from the following organizations:
- Massachusetts Hospital Association (MHA)
- Massachusetts Association of Health Plans (MAHP)
- Massachusetts Medical Society (MMS)
- Massachusetts Association of Patient Account Managers (MAPAM)
- Massachusetts Healthcare Financial Managers Association (HFMA)
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