HHS/CMS Unified Agenda - NPRM

Transcription

1 Attachment Regulation Panel - Durwin Day (HCSC), Tony Benson (BCBSAL), Christol Green (Anthem) August, 29, 10:45 12:00 Durwin Day, Health Information Manager, HCSC HL7 Attachment WG Co-chair, PUG Co-chair WEDI Attachment WG Co-chair, BOD ONC P2 FHIR Task Force Tiger Team Co-chair 1 HHS/CMS Unified Agenda - NPRM HHS Unified Agenda that was published January includes a proposed Attachment NPRM for Aug 2018 th bid=201710&rin=0938 AT38. HHS/CMS RIN: 0938 AT38 Publication ID: Fall 2017 Title: Administrative Simplification; Health Care Claims Attachments (CMS 0053 P) Abstract: This proposed rule would adopt standards and operating rules for attachments based on statutory requirements introduced in the Health Insurance Portability and Accountability Act (HIPAA) and reinforced in the Affordable Care Act. In general, it would apply to circumstances in which a provider attaches clinical information to a transaction that it is being transmitted to a health plan. We are required to adopt standards to facilitate the electronic exchange of clinical information 1

2 List of Standards for Attachments HL7 HL7 CDA R2 Implementation Guide: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Release 2.1 (w/errata) HL7 CDA R2 Attachment Implementation Guide: Exchange of C-CDA Based Documents, Rel. 1 X12 Type 3 Technical Reports (TR3) X12 TR3 for the 275 Transaction X314 Additional Information to Support a Health Care Claim or Encounter X316 Additional Information to Support a Healthcare Service Review X12 TR3 for the 277 Transaction X313 Health Care Claim Request for Additional Information X12 TR3 for the 278 Transaction X217 Health Care Services Review Request for Review and Response WEDI Whitepaper - ACP Guidance on Implementation of Standard Electronic Attachments for Healthcare Transactions Additional HL7 Documents for Reference HL7 Clinical Document Architecture Release 2 (CDA R2) Quick Start Guide for CDA R2 HL7 Companion Guide for C-CDA R2 HL7 Clinical Documents for Payers Set 1 (CDP1) HL7 Digital Signatures and Delegation of Rights Release 1 Rewriting the HL7 FAQs is in progress 2

3 Electronic Attachment Utilization Business Processes Claims Adjudication (i.e., high% unsolicited) Post Adjudication (i.e. appeal/audit) Referral/Notification Prior Authorization Utilization Review /Case Management Itemized Invoices Emerging regulations, i.e. Value Based Payment Quality measures requests and responses (HEDIS data) Transitions of Care (Admit, Discharge, Transfer, and care management Gaps in care (population health analytics) 5 Shared Clinical Documents HL7 Consolidated CDA ATTACHMENTS Consent Forms EOB Home Health EAP Glucose Monitor CCD Discharge Summary History and Physical Care Plan Transfer Summary Notes: Consult Operative Report Procedure Progress Referral Public Health Genomics Biomedical Cancer Reporting Diet/Nutrition CLINICAL DOCUMENTS 3

4 A Brief History of Regulations HIPAA Administrative Simplification, Aug CMS Pilot conducted to test the implementation of the standards and to measure ROI Attachment standards named in the 2005 NPRM Rescinded in 2007 PPACA enhance the HIPAA requirements 2009 ARRA HiTech - Meaningful Use of EHRs, 3 stages Unified Agenda NPRM in August , Data Interchange A Brief History of Standards Since 1997, ASC X12 and HL7 International have been working together to develop standards of attachments X12 selected because Providers and Payers were already exchanging these standard transactions under HIPAA HL7 selected for its standards for structured clinical documents and required human readable text LOINC selected to codify the identity of the request Standards have been continuously updated 2011, Data Interchange 4

5 Focus on LOINC Constraining the Database Payers Request Use the RELMA HIPAA Tab - window, Valid Attachment Requests Lists the codes for Structured and Unstructured Providers Response Use the RELMA HIPAA Tab windows, Documents with Implementation Guides and Documents without Implementation Guides Lists the possible Document types Scale = DOC 9 Convert RFAI from paper to electronic Understanding LOINC What is LOINC? Why use LOINC codes? How do you find them? Which LOINC code is the right one to use? What steps can you take? Review the letter requests for current needs Assign/map LOINC codes to the needed document requests Request new LOINC codes for any gaps Evaluate the proposed rule and standards 10 5

6 LOINC in CDA/C-CDA Documents CDA uses LOINC for Document type codes Section codes Various observations (lab results, vital signs, etc.) Document type codes are most relevant for attachments The document type code in CDA specifies the particular kind of document (e.g. History and Physical, Discharge Summary, Progress Note) LOINC in Consolidated CDA (C-CDA) The C-CDA US Realm Header is required for all valid attachments Requires the use of LOINC codes where SCALE = DOC Structured documents Require specific LOINC codes or value sets cited in the C-CDA spec. Found in the Documents with Implementation Guide tab in RELMA. Unstructured Documents Found in the Documents without Implementation Guide tab in RELMA 6

7 Attachments Implementation Guide (IG) HL7 CDA Attachment Implementation Guide (IG): Exchange of C-CDA Based Documents, Release 1 Standard for Trial Use (STU) Released August 2017 The IG Documents: Approach Background - Structured/unstructured - ISO Object Identifiers (OIDs) - Base64 Encoding - Document Succession Classification using LOINC Business requirements Rules (conformance requirements) HL7 Attachments IG Classification using LOINC Overview of LOINC Use of LOINC in Identifying Documents LOINC Attachment Code Sets Use of LOINC in CDA Documents Requesting an Attachment Submitting an Attachment Navigating LOINC to Identify Valid Attachment Types Updating LOINC and the Attachment Document Type Codes 7

8 CDA/RELMA Discrepancies Sometimes LOINC codes are deprecated after they are cited in C-CDA Deprecated LOINC codes do not appear in the HIPAA tab in RELMA Better coordination between Regenstrief and HL7 needed to address this issue not shown in RELMA Slides courtesy of Dr. Abhyankar and Rick Geimer Dr. Swapna Abhyankar is the Associate Director for Content Development for LOINC and Health Data Standards at the Regenstrief Institute. Rick Geimer, Chief Innovation Officer, Lantana Consulting Group, and co-chair at HL7 for Structured Documents and FHIR. 16 8

9 OUTLINE Three ways to access LOINC Key concepts Using the RELMA HIPAA Attachments tab Finding valid attachment requests and responses Using RELMA or online search Using LOINC table Search tips, examples THREE WAYS TO ACCESS LOINC 1. Regenstrief LOINC Mapping Assistant (RELMA ) LOINC table in a variety of formats Primary LOINC content is exactly the same no matter which format you use as long as you get the updates twice a year, with each new LOINC release (usually June and December) 9

10 Tool #1: RELMA REgenstrief LOINC Mapping Assistant (RELMA ) Free Windows-based mapping utility developed by the LOINC software team Use to search the LOINC database and help map local codes to LOINC Have to update twice a year with the LOINC release in order to get new LOINC content Need admin rights to install Available from: Tool #1: RELMA (cont.) Two ways to find attachment request and response codes in RELMA HIPAA Attachment tab Created specifically for LOINC Attachments content Includes all of the LOINC terms and associated information (e.g., C-CDA document and section terms) relevant to Attachments Search screen 10

11 Tool #2: Free online search tool Great for looking up a few codes at a time Fast, easy to use Content updated twice a year with each LOINC release Requires a free LOINC account Tool #3: LOINC download file LOINC table available in.csv and.mdb formats Updated twice a year Convenient if working offline Available from: 11

12 LOINC TOOLS SUMMARY Free Can use offline Requires user action to get the latest content twice a year* Automatically includes new content twice a year* Contains all of the information necessary to find valid attachment request/response codes *If you do not download the latest release of RELMA or the LOINC table after each release, the content you see will be different from what you can find online (i.e., Some new codes are missing from RELMA ) DEFAULT SETTINGS In both RELMA and the online search, the default setting is to NOT include terms with a status of DEPRECATED If you want to include DEPRECATED codes in your search results, you will have to change you settings If you are getting inconsistent results between the online search, RELMA, and/or the download file, make sure #1, you have the latest release of RELMA and/or the download file #2, the search settings match 12

13 INCLUDING DEPRECATED CODES IN RELMA SEARCH Go to Hierarchy & Search limits tab Make sure the DEPRECATED box is checked INCLUDING DEPRECATED CODES IN ONLINE SEARCH Go to Options -> Search Constraints Make sure the DEPRECATED box is checked 13

14 KEY CONCEPTS #1 Documents with implementation guides ( with HL7 IG ) = documents that have a clinically-relevant HL7 CDA implementation guide (IG) that uses the U.S. Realm header Documents without implementation guides ( without HL7 IG ) = documents that don t (yet) have a clinically-relevant HL7 CDA IG that uses the U.S. Realm header Selected by the HL7 Attachments Working Group KEY CONCEPTS #2 Valid HL7 Attachment Request = LOINC terms that payers can use to request claims attachments Two types The "top level" (i.e., most generic) document codes with HL7 IG Document codes without HL7 IGs that have been approved by the HL7 Attachments Working Group Valid HL7 Attachment Responses = LOINC terms that providers may use to send information in response to a payer request Also two types All of the valid request terms above More specific document codes with HL7 IGs 14

15 Using the RELMA HIPAA Attachments tab CLAIMS ATTACHMENT REQUESTS Includes all LOINC terms that can be used by payers to request claims attachments Divided into those that have HL7 IGs and those that don t 15

16 CLAIMS ATTACHMENT REQUEST MODIFIERS Modifier codes to send with the attachment request To constrain responses By time By CDA template CLAIMS ATTACHMENT RESPONSES WITHOUT IG Document codes that do not have associated HL7 CDA IGs but are approved as attachment response codes Exactly the same list as the Documents without implementation guide set on the Valid attachment requests tab NOTE: This list contains a small subset of LOINC document codes without associated CDA IGs i.e., not all LOINC document codes are valid attachment responses 16

17 CLAIMS ATTACHMENT RESPONSES WITH IG: OVERVIEW OF DOCUMENTS WITH IMPLEMENTATION GUIDE TAB #1: Dropdown menu of HL7 CDA implementation guides with the U.S. Realm header #2: Expandable list of document types associated with the IG selected in #1 #3: List of recommended Section and Entry codes associated with the IG (#1) and document type (#2) # 1 # 2 # 3 CLAIMS ATTACHMENT RESPONSES WITH IG, STEP 1 Choose the appropriate HL7 IG using the dropdown (C-CDA R2.1 is the default) The list of document types will change depending on the selection 17

18 CLAIMS ATTACHMENT RESPONSES WITH IG, STEP 2 Click on the + next to the appropriate document type to see all of the LOINC codes for that type of document All of the codes that are shown are valid response codes The top-level code, indicated by a, is a valid attachment request code All of the starred codes together comprise the Documents with implementation guide list on the Valid attachment requests tab CLAIMS ATTACHMENT RESPONSES WITH IG, STEP 3 Use the right pane to see the Section and Entry codes that are contained in the selected IG (#1) and document type (#2) 18

19 FINDING REQUEST/RESPONSE CODES WITHOUT USING RELMA HIPAA ATTACHMENT TAB If you are not using the HIPAA Attachments tab in RELMA, you can get all of the same information using the RELMA search, online search, or LOINC table Very easy to find valid request and response codes using all of the alternate methods Pretty easy to get specific CDA IG, Section, and Entry information using RELMA search and online search If you want to get specific CDA IG, Section, and Entry information using the LOINC table, please see me Key fields: ValidHL7AttachmentRequest: Use this field to identify valid request terms HL7AttachmentStructure: Use this field to differentiate between terms for which an HL7 IG exists and those for which no HL7 IG exists SEARCHING FOR REQUEST CODES ValidHL7AttachmentRequest:TRUE Combine with HL7AttachmentStructure field to find valid request terms that do or do not have HL7 CDA IGs HL7AttachmentStructure:IGexists HL7AttachmentStructure:NoIGexists 19

20 SEARCHING FOR RESPONSE CODES HL7AttachmentStructure:IGexists All LOINC codes that are valid response codes and have HL7 CDA IGs HL7AttachmentStructure:NoIGexists All LOINC codes that are valid response codes and do not have HL7 CDA IGs (remember, the list of request and response codes that do not have associated IGs is exactly the same) BONUS: HL7AttachmentStructure:TRUE Identifies all LOINC codes that are valid response codes CDA IG, SECTION, AND ENTRY INFORMATION USING RELMA OR ONLINE SEARCH The details page for each term includes a variety of information, including associated HL7 CDA IGs and Section/Entry codes Open the details page by Double-clicking on the row in the RELMA search screen Clicking on the LOINC code in the online search 20

21 USING THE LOINC TABLE TO FIND REQUEST AND RESPONSE CODES Use the same two fields as for searching ValidHL7AttachmentRequest HL7AttachmentStructure column header is HL7_Attachment_Structure Filter on the relevant column to find all of the LOINC terms REQUEST CODES: VALIDHL7ATTACHMENTREQUEST = Y 21

22 RESPONSE CODES WITH IG: HL7_ATTACHMENT_STRUCTURE = IG exists RESPONSE CODES WITHOUT IG: HL7_ATTACHMENT_STRUCTURE = No IG exists 22

23 SEARCH TIP #1: INCLUDE RELEVANT DETAILS If you need a LOINC term for an Oncology Discharge summary Discharge = 384 terms Discharge summary = 108 terms Oncology discharge summary = 3 terms If you need a term for Influenza RNA in CSF flu = 4537 terms Influenza RNA = 101 terms Influenza RNA CSF = 2 terms SEARCH TIP #2: USE THE - OPERATOR If you are not sure about the exact concept, it s okay to start broad and then narrow down based on what you want to exclude Example #1 need a code related to Cardiology Cardiology = 1155 terms Cardiology -Scale:Qn = 239 terms Cardiology -Scale:Qn -Outpatient = 233 terms Cardiology -Scale:Qn -Outpatient Pediatric = 10 terms Example #2 need a code related to Speech Speech = 182 terms Speech Scale:Doc = 30 terms Speech Scale:Doc -Counseling -Discharge Hospital = 24 terms 23

24 SEARCH TIP #3: USE ANCILLARY SEARCH FIELDS Every LOINC terms has lots of attributes outside of the primary Parts A few that I find useful are: Class VersionLastChanged Chngtype And of course HL7AttachmentStructure and ValidHL7AttachmentRequest Example #1 new Microbiology codes added in last release Class:micro versionlastchanged:2.64 chngtype:add If you leave off Class, this query will find all new terms in the Microbiology class as well as with Microscopy as the Method and Micro in the Component Example #2 attachment response codes DEPRECATED in last release HL7attachmentstructure:TRUE versionlastchanged:2.64 chngtype:del = 31 terms 24