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Claims and Coding


How to plan for the new era of data management


The transitions to HIPAA EDI version 5010 and ICD-10 will only further complicate electronic data gathering, reporting and security.


By Mark Danis S


tage 1 of meaningful use is now fi nalized, and provider incentives will certainly result in an increased use of certifi ed electronic health re- cords (EHRs), exchange of electronic health information and submission of quality measures. How- ever, meaningful-use requirements and their incentives apply only to healthcare providers and, even then, only Medicare or Medicaid acute-care hospitals, critical-access hospitals and eligible providers. A signifi cant segment of the provider community, not to mention the healthcare ecosystem, is ignored: alternative care providers, nurs- ing homes, mental health providers, payers, suppliers, vendors and, last but not least, patients. All stakeholders will need to be involved to meet the ultimate goals of meaningful use: improved quality and reduced cost. For those stakeholders not directly af- fected by meaningful use and provider incentives, other healthcare industry initiatives may pave the way for their involvement and for the meaningful use of data. Meaning- ful use will require transformational changes in healthcare delivery for all stakeholders: new systems, additional staff training and education, redesigned work fl ows and – per- haps most challenging – meaningful use of data. HIPAA EDI version 5010 and ICD-10 mandates will provide an opportunity for various health-industry stakeholders to examine their people, processes and technology. These projects, if structured around a com- prehensive data-management plan, will allow entities to benefi t directly from the new clinical and fi nancial data that these initiatives provide. Unfortunately, the fi nal Stage 1 meaningful-use objectives removed the require- ments for checking insurance eligibility electronically and submitting claims electronically to both private and public payers. It is almost certain, however, that these two objectives will be present in Stage 2, which begins in 2013. This expectation, coupled with the required implementations of HIPAA EDI version 5010 and ICD- 10, should motivate healthcare stakeholders to examine their current business operations related to coding and claims and to identify opportunities for increased ef-


24 December 2010


fi ciency, effectiveness and value in those administrative functions. Development of a data-management plan will provide the framework for assessment, analysis, imple- mentation and improvement.


Data management is not solely an HIT concern; it is the responsibility of all those who create, transmit and receive data.


Data management requires both the effi cient and effective use of healthcare data, as in to improve clini- cal outcomes, as well as the protection of that data via physical and technological safeguards to ensure privacy and security. Healthcare data can no longer merely be collected or reported, but must be analyzed with the intention of using it in the future to identify opportunities for improvement and to act on those opportunities. The nationwide adoption of EHRs will exponentially increase the volume of electronic personal health information (PHI) and will greatly increase the demands on healthcare stakeholders to ensure the privacy and security, as well as the integrity, of the data. An overlooked but arguably essential third component of effective data management is ensuring appropriate data inputs – a component that will be highlighted in coming years due to the exponential increase in raw electronic data available. In January 2012, HIPAA EDI version 5010 will provide much-needed standardization of data in claims-related transaction sets. The initial implementation of HIPAA EDI transaction sets in 2003 failed to provide stakehold- ers with relief from burdensome claims requirements. Individual payers were still able to defi ne their specifi c requirements for data content and presentation via the use of “companion guides” for each transaction set. The transaction-specifi c implementation guides developed at the national level provided merely a list of ingredients; the payer-specifi c companion guides were the recipe to be followed to submit an acceptable transaction. This lack


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