Automating Attachments: The New HIPAA Standard - government standards for electronic transmission of medical records

Healthcare Financial Management, July, 2001 by James J. Moynihan

A proposed rule for the claims attachment standard mandated by the Health Insurance Portability and Accountability Act (HIPAA) of 1996 is expected to be published in the summer of 2001. This standard for the electronic transmission of attachments to healthcare claims will be especially important to hospital patient financial services professionals. Payers are required to comply with this standard by October 2003, although Medicare Part A fiscal intermediaries likely will begin implementing the standard well before then. Adoption of the standard by payers and providers should streamline the claims process and speed payment. In addition, use of the standard will facilitate the exchange of clinical data among providers. Providers should consider whether the proposed implementation guideline for the standard meets their requirements and make their views known during the comment period.

For many hospitals, the UB-92 has become a mere cover sheet for attachments. While electronic claims volume has increased markedly among physicians and other nonhospital providers, hospitals have had less success in eliminating paper. Payers continue to ask hospitals for supplemental information that usually must be supplied on paper. The EDI standard chosen for the automation of healthcare claims attachments is identified as the Additional Information to Support a Health Claim or Encounter (American Standards Committe [ASC] X12 275) in its implementation guideline.

The implementation guideline for the ASC X12 275 is coupled with an implementation guideline for an electronic request for additional information, the Health Care Claim Request for Additional Information (ASC X12 277). In certain circumstances, a payer would send an ASC X12 277 transaction to a provider electronically, referencing a claim sent by that provider with information such as the subscriber/dependent name; the patient account number; and related charges, codes, and dates from the claim. These data should be sufficient to allow the provider to identify the relevant claim. The ASC X12 277 also includes a trace number for each request assigned by the payer. When the information requested is returned by the provider, the trace number is used to associate the attachment information with the appropriate claim.

Several business and systems issues need to be addressed by the proposed use of the standard. For instance, how will payers electronically describe the information they need to adjudicate the claim, and how will providers be able to identify that information in their information systems for extraction and transmission to the payer? ANSI-accredited standards organizations ASC X12 and HL7(Health Level Seven) joined forces to develop a solution to these challenges.

The solution proposed by both ASC X12 and HL7 standards developers requires payers and providers to adopt a common code list for the description of attachment data. The information being requested is described through the use of Logical Observation Identifier Names and Codes (LOINC). LOINC is a consortium of laboratories, system vendors, hospitals, and academic institutions organized by a variety of government agencies and foundations to create formal names and codes for laboratory results and clinical variables with numbered, coded, or narrative text. The LOINC codes were designed specifically to provide a universal identifier for HL7/ASTM observation reporting.[a] Payers can request specific information by using the LOINC codes. Payers also can identify when the request should be fulfilled before the claim is sent on through the adjudication process.

Providers that plan to send electronic healthcare attachments will use the ASC X12 275 standard. The standard's use is far broader than just responding to payer requests. The standard was designed to allow providers to transmit portions of the clinical patient record to both payers and providers. Information in the electronic medical record may be in a variety of electronic standards and formats widely used by providers. The ASC X12 275 standard was designed to act as an "envelope" in which the electronic information in other standards and formats could be inserted. Hospitals could use this standard for many provider-toprovider data exchanges as well as communicating with payers.

The draft implementation guideline for the attachment transaction contains HL7 "booklets" for ambulance, clinical reports, emergency department, laboratory results, medications, and rehabilitation services. The automation of attachments in the ASC X12 277/275 exchange probably will be initiated by Medicare, which is committed to HIPAA-compliant automation. Providers should be working with their fiscal intermediary to determine the time frame for implementation. The opportunity exists to speed payer payment when requested data can be extracted quickly from hospital information systems (HIS) and placed in a compliant ASC X12 275 standard. HIS professionals should be evaluating their systems' ability to create the HL7 messages needed to support the standards. The proposed rule would be enhanced if it included support for the transmission of image files for the many providers and payers that have imaging capabilities to scan on demand or have invested in imaging document management systems but do not have the ab ility to deal with HL7 messages. For many providers and smaller payers, transmission of scanned documents may be less expensive than electronic transmissions. It is critical that hospitals evaluate these implementation guidelines and comment on the proposed rule's IT solution.