2010 ubo/ubu conference title: bill spawning – hipaa 837i and 837p session: t-6-1100

2010 UBO/UBU Conference

Title: Bill Spawning – HIPAA 837I and 837P

Session: T-6-1100

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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”)

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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 only @#$%<>…

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.

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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.

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?

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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”

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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”

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Transmission Control

Functional Group Header and at the end Trailer– Says what kind of transaction, such as 837I, 837P,

HIPAA 837 - Health Care Claim (Professional, Institutional, Dental)

HIPAA 835 - Health Care Claim Payment/Advice Transaction HIPAA 834 - Benefit Enrollment and Maintenance HIPAA 270 - Health Care Eligibility/Benefit Inquiry HIPAA 271 - Health Care Eligibility/Benefit Response HIPAA 276 - Health Care Claim Status Request HIPAA 277 - Health Care Claim Status Notification HIPAA 278 - Health Care Review Information HIPAA NCPDP DO – Retail Pharmacy

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How Does The OUTSIDE Fit Together?

Detail Segment – 837P

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Communications Transport Trailer

Interchange Control Header

Functional Group Header

Detail Segment – 837I

Detail Segment – 276

Functional Group Trailer





Interchange Control Trailer

Communications Transport Protocol

Detail Segments

HIPAA 837 - Health Care Claim – Institutional– Professional– Dental

HIPAA 835 - Health Care Claim Payment/Advice Transaction HIPAA 834 - Benefit Enrollment and Maintenance HIPAA 270 - Health Care Eligibility/Benefit Inquiry HIPAA 271 - Health Care Eligibility/Benefit Response HIPAA 276 - Health Care Claim Status Request HIPAA 277 - Health Care Claim Status Notification HIPAA 278 - Health Care Review Information HIPAA NCPDP DO – Retail Pharmacy

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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

1000 Header

HEADER

ST*837* 8675309*00510X223~ Begin hierarchical transaction –

BHT*0019*00*0123*20110309*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 – 20110309 – date of transmission in CCYYMMDD– 0932 – time in HHMM, so 9:32 am– “CH” – chargeable

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1000A Submitter

1000A Submitter– NM1*41*2*AF Central Billing*****46*164.65.172.66~

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 “164.65.172.66” – our address

– PER*IC*Fred Darcy*TE*7036810000~ PER – submitter EDI contact information “IC” means Information Contact Fred Darcy is the free-form name “TE” means telephone and then the number

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1000B Receiver

1000B Receiver– NM1*40*2*AF Clearing House*****46*127.0.0.1~

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 “127.0.0.1” – address for where we are sending the

package

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2000A Billing – Hierarchical and Billing Provider

HL – Billing Provider Hierarchical Level– HL*1**20*1~ notice this is the 1st “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

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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)

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2010AA Billing Provider Name

NMI*85*2*56th Medical Group Luke*****XX*1194700971~– 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– 1194700971 – NPI for Luke

N3*7219 North Litchfield Road~ N4*Luke AFB*AZ*85309~

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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*8008675309*ex*56~– PER – billing provider contact info segment,

situational, if different from submitting info– “IC” means information contact

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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

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2000B Subscriber Loops

2000B Subscriber HL Loop HL*2*1*22*0~

– notice this is the 2nd “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

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Central Billing Events Repository Data Start HERE

2000B Subscriber Loops

2010BA Subscriber– SBR*P*18*GRP01020102******CI~

2010BA Subscriber name– NM1*IL*1*Doe*John*T**Jr*MI*123456~– N3*123 Main Street~– N4*Phoenix*AZ*85309~– DMG*D8*19690815*M~– REF*SY*123456789~ (subscriber 2nd ID {SY is “SSAN

is next”}, situational, not required)

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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 2nd ID, situational,

not required)– FY means “claim office number”

REF*G2*1234~ (Reference – Billing Provider 2nd ID, situational, not required)– G2 means provider commercial number

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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*19700607*F~

In the patient demographic segment, the date is the birth date

F means female

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2300 Claim

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

2300 Claim Information

CLM*0009OUT201103010111*500***11:A:1*Y*A*Y*I~– 0009OUT201103010111 (DMIS ID 0009; outpatient;1

Mar 2010; 111th 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

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CLM*0009OUT201103010111*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

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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*20110301-20110305~ DTP – Date or time or period “434” means “statement” “RD8” means time will be CCYYMMDD-CCYYMMDD 20110301-20110305 means 1 Mar 11-5 Mar 11

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DTP – Date or Time or Period– DTP*435*DT*201103011242~

DTP – Date or time or period “435” means “admission” “DT” means the time will be expressed in Format

CCYYMDDHHMM 201103011242 is an example of 1 Mar 2011 12:42 pm

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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

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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

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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

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HI*BBR:0B110F4:D8:20110302~– “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:D8:20110304*BBQ:4A023N8:D8:20110304~– BBQ is other ICD-10-PCS procedures– D8 is that a date in the CCYYMMDD format follows

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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)

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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)

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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)

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2310A Attending Provider Name

NM1*71*Jones*John****XX*1357986420~– “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”

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2310 Additional Providers

2310B NM1*72*1*Meyers*Jane*****XX*1357986420~– “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*1357986420~

– “ZZ” is mutually defined to indicate “other operating physician”

– Usually not needed, usually only one surgeon 2310D NM1*82*1*Doe*Jane*C***XX*1357986420~

– “82” is rendering provider

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2310E Service Facility

2310E NM1*77*2*Bolling Clinic*****XX*1468097532~

– “77” is Service Location (other than the doctor’s office)

– “2” is non-person entity N3*1300 Angell Street~ N4*Bolling AFB*DC*20032~

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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*1246809753~– “DN” is referring provider– “1” is a person – XX is “the NPI is next”

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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

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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.

2330B Other Payer Name

NM1*PR*2*Another Insurance Group*****PI*1123344~– “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

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2400 Loops

2400 Service Line 2420C Rendering Provider 2420D Referring Provider

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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

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2400

DTP*472*D8*20110302~– DTP is date or time or period segment– “472” is a service– D8 indicates date format will be CCYYMMDD– 20110302 is 2 Mar 11

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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*8675309~– SE is a transaction set trailer– 1230 is the number of segments included in the

transaction including ST and SE segments– 8675309 is the same transaction set control number

in the ST02 that began the transaction

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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

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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 1st payer’s input and send to the second payer

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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

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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

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

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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

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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)

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

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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

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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”)

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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.

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 01 Discharged to home or self care (routine discharge) 02 Discharged/transferred to a short-term general hospital for inpatient care. 03 Discharged/transferred to SNF with Medicare certification in anticipation of

covered skilled care (effective 2/23/05). See Code 61 below. 04 Discharged/transferred to an Intermediate Care Facility (ICF) 05 Discharged/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.

06 Discharged/transferred to home under care of organized home health service organization in anticipation of covered skills care (effective 2/23/05).

07 Left against medical advice or discontinued care 08 Reserved for National Assignment *09 Admitted as an inpatient to this hospital

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10-19 Reserved for National Assignment 20 Expired (or did not recover - Religious Non Medical Health Care Patient) 21 Discharged/transferred to Court/Law Enforcement 22-29 Reserved for National Assignment 30 Still patient or expected to return for outpatient services 31-39 Reserved for National Assignment 40 Expired at home (Hospice claims only) 41 Expired in a medical facility, such as a hospital, SNF, ICF or freestanding

hospice (Hospice claims only) 42 Expired - place unknown (Hospice claims only) 43 Discharged/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.

44-49 Reserved for national assignment 50 Discharged/transferred to Hospice - home 51 Discharged/transferred to Hospice - medical facility 52-60 Reserved for national assignment

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61 Discharged/transferred within this institution to a hospital based Medicare approved swing bed.

62 Discharged/transferred to an inpatient rehabilitation facility including distinct part units of a hospital

63 Discharged/transferred to long term care hospitals 64 Discharged/transferred to a nursing facility certified under Medicaid but not

certified under Medicare 65 Discharged/transferred to a psychiatric hospital or psychiatric distinct part

unit of a hospital. 66 Discharged/transferred to a Critical Access Hospital (CAH). (effective

1/1/06) 67-69 Reserved for national assignment 70 Discharge/transfer to another type of health care institution not defined

elsewhere in the code list. (effective 4/1/08) 71-99 Reserved 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

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2010 ubo/ubu conference title: bill spawning – hipaa 837i and 837p session: t-6-1100

Documents

standard hipaa

dental hipaa

maintenance hipaa

bill spawning hipaa

individual taxes hipaa

entire transmission

transmission example

correct data