All official NCVHS documents including meeting transcripts are on the NCVHS Website ( See transcript and PowerPoint presentation for further information

Department of Health and Human Services


Subcommittee on Standards Hearing

November 17-18, 2011

Holiday Inn Rosslyn at Key Bridge
1900 N. Fort Meyer Drive
Arlington, VA 22209

Meeting Minutes

The National Committee on Vital and Health Statistics Subcommittee on Standards convened on November 17-18, 2011 in Arlington, VA. The meeting was open to the public and was broadcast live on the Internet. A link to the live broadcast is available on the NCVHS homepage.

Committee members:

  • Walter G. Suarez, M.D., M.P.H., Co-Chair
  • Judith Warren, Ph.D., R.N., Co-Chair
  • John J. Burke, M.B.A., M.S. Pharm.
  • Justine M. Carr, M.D. (11-17 only)
  • Raj Chanderraj, M.D., F.A.C.C.
  • Bruce B. Cohen, Ph.D.
  • Leslie Pickering Francis, J.D., Ph.D.
  • Larry A. Green, M.D.
  • Mark C. Hornbrook, Ph.D.
  • Linda L. Kloss, M.A., RHIA, CAE, FAHIMA
  • Vickie M. Mays, Ph.D., M.S.P.H.
  • Blackford Middleton, M.D., M.P.H., M.Sc.
  • Len Nichols, Ph.D.
  • Sallie Milam, J.D., CIPP/G
  • William J. Scanlon, Ph.D.
  • Paul C. Tang, M.D. (by phone)


  • W. Ob Soonthornsima
  • James Walker, MD, FACP

Lead Staff and Liaisons

  • Lorraine T. Doo, M.P.H., Lead Staff
  • J. Michael Fitzmaurice, Ph.D., AHRQ
  • Marjorie Greenberg, NCHS/CDC, Executive Secretary
  • Debbie Jackson, NCHS
  • James Scanlon, ASPE
  • Jim Sorace, M.D., ASPE


  • Shantanu Agrawal, CMS
  • Irfan Ahmad, TCH
  • George Arges, AHA
  • Tammy Banks, AMA
  • Robert Barbour, AMA
  • Keith Bateman, PCIAA
  • Don Bechtel
  • Rhonda Buckholtz, AAPC
  • Laurie Burckhardt
  • Mary Lynn Bushman, CMS
  • Zabeen Chong, CMS (telcon)
  • Melanie Combs-Dyer, CMS
  • Jim Daley, ICD-10, BCBS SC
  • Laurie A. Darst, 5010, Mayo Clinic
  • Durwin Day, HCSC, BCBC IL
  • Doug Fridsma, ONC
  • Jan Estep
  • Annette Gabel, NCPDP, Medco
  • Julie Gackenbach, NAMIC
  • Lynne Gilbertson, NCPDP
  • Michael Herd
  • Charles Jaffe
  • Chris Jagmin, Aetna
  • Barry Keene, Keene Research & Development
  • Gail Kocher, BCBSA
  • Greg Krohm, IAIABC
  • Connie Leonard, CMS
  • Gwen Lohse
  • Holly Louie, PMI
  • Susan Maynard, State Farm
  • Jim McKinley, BCBSAL
  • Debbie Meisner
  • Craig Miller, Vangent, Inc.
  • Dave Nicholson, HBMA, PMI
  • Ruth-Ann Phelps, VA
  • John Quinn, Health Level Seven Intl.
  • Wes Rishel, Gartner
  • Elizabeth Reed, Medicaid/CMCS
  • Niles R. Rosen, NCCI, Correct Coding Solutions
  • Mari Savickis, AMA
  • Donna Schmidt
  • Tony Schueth, Point of Care Partners
  • Pat Squires, D.C. Medicaid
  • Chris Stahlecker, Medicare
  • Don St. Jacques, Jopari Solutions
  • Deb Strickland, Tibco
  • Rob Tennant, MGMA
  • Lisa Wichterman, Workers Compensation, MN Dept. of Labor & Industry
  • Margaret Weiker, HP
  • Sherry Wilson, Jopari Solutions
  • Bruce Wood, AIA

Others Present:

  • Bill Alfano, BCBSA
  • Peter Barto, PWC
  • Gary Beatty, Deloitte Consulting LLP
  • Robert Bowman, CAQH
  • Robert B. Burleigh, CHBME
  • Jay Crowley, FDA
  • Michael J. DeCarlo, BCBSA
  • Gary L. Dickinson, CentriHealth
  • Michelle Dougherty, AHIMA
  • Bill Finerfrock, Capitol Associates, Inc.
  • Rachel Foerster, Rachel Foerster & Associates, Ltd.
  • Douglas Hadley, Cigna HealthCare
  • Holly J. Kinnamon, Holly J. Kinnamon, LLC
  • Steven S. Lazarus, BIG
  • Patrick McLaurin, Mitchell
  • Erin Richter, CAQH
  • Dan Rode, AHIMA
  • Laurie F. Rowe, HCOA
  • James A. Schuping, WEDI
  • Phillice J. Spencer, D.C. Medicaid
  • John Spiegel, CMS
  • Steve Stevens, Jopari Solutions
  • David Susanto, Accenture
  • Jeanette Thornton, AHIP
  • Christine Tremblay, NaviNet, Inc.
  • Peter Walker, Aetna
  • P. John White, AHRQ
  • Devin B. Zatorski, BCBSA

Note: The transcript of this meeting and speakers’ slides are posted on the NCVHS Web site, Use the meeting date to locate them. For final versions of NCVHS documents discussed in the meeting, see “Reports and Recommendations.”


Thursday, November 17, 2011


  • A series of observations will be assembled and presented to the full Committee, noting that process recommendations will be vetted through the Committee.
  • Recommendations about parts of Section 10109 and claims attachments will be ready for presentation to the HIT Standards and Policy Committees by the first 2012 NCVHS meeting.
  • The industry was asked for ideas about 2012 hearings topics (which will include 5010 implementation; ICD-10; the transition to new operating rules in early 2013).
  • A request was made for participants to send Dr. Doo, Dr. Warren or Dr. Suarez ideas for how to identify metrics, measures or impact on big implementations such as 5010.
  • Further thoughts about administrative simplification cost savings should be sent to Dr. Doo.


Judith Warren, Ph.D., R.N.; Co-Chair; Walter G. Suarez, M.D., M.P.H., Co-Chair

Historical Perspectives on Claim Attachments — Wes Rishel, Gartner

ONC Perspectives on Attachments and Clinical Messages — Doug Fridsma

SESSION I    Current Business Practices in Claim Attachments: Priority Attachments, Business Practices, Mechanisms for Request and Submission, Other

Provider Perspective  Rob Tennant, MGMA; Robert Barbour, AMA
VA     Ruth-Ann Phelps
Payer Perspective   Gail Kocher, BCBSA
Medicare EsMD Project  Melanie Combs-Dyer, CMS; Craig Miller, Vangent/ONC
Medicare Perspective       Chris Stahlecker, Medicare
Clearinghouse Perspective  Debbie Meisner, Emdeon
Claims Attachment Pilot     Laurie Darst; Laurie Burckhardt
Medicaid Perspective Elizabeth Reed; Donna Schmidt


Dr. Suarez summarized themes, including strong support for moving toward electronic standards prior to January 2014. Specifically, the recommendation was to “start simple” (e.g. human readable approach) but move toward greater complexity (e.g., computer variant approach). Strong value was placed on an unsolicited approach although concerns about possible abuse of requests for attachments were raised. Operating rules have recognized value although guidance is needed for timing, submission reasoning, etc. Efforts are being made to reduce and limit the number of needed and requested attachments. Priority areas remain consistent (e.g., attachments for authorization requests; medical necessity; miscellaneous procedures; Code 22; invoices and documentation; the ambulance; operative report; and the lab report). General support exists for the 275 (X12) wrapper. It is important to name the operating rule authoring entity to help the industry move toward a consistent and complete set of operating rules that reduces variability across payers and states.

It behooves the payer industry to educate providers about what goes into claims attachments (and when they should be sent, etc.). Partnerships with organizations such as the AMA were seen as beneficial. Discussion ensued about payment and technology opportunities, with a recommendation to use new technologies but not necessarily throw out all payment mechanisms currently in use. Medicaid often uses prior authorization and Medicare now has a mandatory prior authorization program.

One missing internet building block is an ability to track digital signatures of individual providers of administration and clinical work. Because the complexity and costs of doing this are so high, government agencies must work together. The schism between structured and unstructured documents was described (a later clarification noted that “structured” really means “semi-structured”). The semi-structured approach should be taken into account. With regard to web submission, it is important to set up relationships with everyone submitting data (example given). There are challenges with identifying the submitter. The Direct Project commissioned by ONC exemplifies an ability to securely push and transmit information. There is a way for large “technological wholesalers” to provide support to physicians, including EHR venders. E-prescribing technology venders are an additional resource. CMS encourages its health information handlers to accept Direct from their providers. In cases where PDFs and medical document images are accepted, the XDR or X12 wrappers provide significant meta-data such as provider identities. A concern was raised about Medicare’s relatively few (i.e., two million) attachments (although under the Medicare fee-for-service program, 16% of their claims hadan attachment requirement). Medicare’s Medical Review Department searches out improper payments, excluding first, second and third levels of appeal and other types of Medicare documentation for providers.

SESSION II   Claim (and Other) Attachment Standards and Operating Rules: Current Developments and Future Directions

HL7 SDO Corporate Perspective John Quinn; Charles Jaffe
X12 Mary Lynn Bushman; Margaret Weiker
WEDI Don Bechtel
CAQH/CORE Gwen Lohse
Other Attachment Types:
Prior Authorization – Rx (ePA) Tony Schueth, Point of Care
Other Pharmacy Lynne Gilbertson, NCPDP


For HL7, work done in priority areas was identified as more consistent across the board. Ideally, there would be standards for any type of attachment. How are attachments with defined templates at CDA reconciled? For ten of fifteen priority areas with no defined CDA templates, how can reconciliation happen? Mr. Day explained the nine attachment types in the CDA Consolidate Guide (publication date December 2011) with regard to reconciliation; inclusions; and structured or unstructured scenarios. Other attachment types from the original set (including rehab services; ambulance; lab results; and medications) should be reconciled within the next fifteen months. In addition, collaboration with the Regenstrief Institute is producing a section in the LOINC database that lists LOINC codes (examples given for identifying unstructured attachments). A Patient Information Unspecified Content (PIUC) list previously used will move to an external database to facilitate additions. New LOINC codes could be added every six months. A published terminology database, with LOINC already mapped into SNOMED, will be managed by the National Library of Medicine. The need for future attachments is aligned with ONC meaningful use requirements, noting a different and effective high-speed track inside of HL7.

An HL7 project lead by Gary Dickenson focuses on use case simplification and highlights movement forward of all future CDA developments. Value added of moving toward this methodology includes using the LOINC database as an external code set. Published semi-annually, the database can be used by regulation to reference new attachment types or new unstructured content immediately.

Currently, claim denials on the 835 with CARC and RARC codes are most commonly used to discern a need for more information. In the future, it would be easier, less expensive and more timely to do a 277 request for additional information because the LOINC code specifically states what is needed. A 277 transaction would replace a paper claim. Dental attachments would primarily flow in the same way. Discussion about a digital signature standard followed, noting support in the CEA for non-repudiation and attestation on digital electronic-encrypted signatures. Customers have required digital signatures within the CDA construct of the EsMD’s Project although it is not clear what the signatures authenticate. An operational function that is a real-world test model is valuable because it provides an opportunity to dialogue with consumers (example of specific use case given).

A concern was raised about the request for additional information standards for medical information going to pharmacists and insurance plans, which expands the practice scope of what physicians do. A standard must support the business case. What the attachments and requests are and how they are used continue to be a gray area for physicians. The challenge may lie in that gray area between SDO implementation guide and operating rule. The gray area within claims must be addressed. Some participants suggested that other providers and health plan representatives get involved in policy workgroups and committees to move the planning and executive processes along that take state regulations into account. Also discussed was how to get providers and health plans to work on the standard (WEDI is doing outreach). The provider/end user experience must be taken into consideration.

The meeting was adjourned at 5:35 p.m.

Friday, November 23, 2011


Judith Warren, Ph.D., R.N.; Co-Chair; Walter G. Suarez, M.D., M.P.H., Co-Chair

SESSION I — Provider Enrollment Forms

CAQH/CORE Gwen Lohse
X12 Gail Kocher
AMA/AHA Mari Savickis; George Arges (via telcon)
ACH/Banks Irfan Ahmad, TCH
HBMA Dave Nicholson, HBMA
Medicare Zabeen Chong, CMS (via telcon)


Dr. Suarez highlighted key presentation points. Various national systems and methods collect physician data (e.g., NPI; UPD; vendors; directories). Defining the scope of what needs to be done is critical to developing a general framework; defining common definitions and the role of standards and the operating rules; and tackling the issue of enrollment with its various meanings and processes. A multi-stakeholder group (across vendors, payers, providers and the banks) was recommended to identify initial steps and periodically bring recommendations to NCVHS (examples of healthcare task forces given). The 274 is actively being used by health plans and providers for bulk enumeration for basic enrollment and more broadly, for provider directories. In terms of electronic funds transfer, CAQH has brought various organizations together to identify issues and make recommendations for a ballot.

Today’s testimony conveyed more about business and operating rules than about the actual standard. Input was requested about the benefit of a centralized data repository for the general enrollment of providers as well as for EFT and other purposes. In response, privacy concerns were mentioned; and interfaces were suggested as an alternative (e.g., between CAQH’s UPD and the PECOS system). An interface between the PECOS system and the NPPES would also be helpful. If interfaces and security are sound, one central and organized information site would cut down on work and be seen as more attractive to some. The relationship between the databases cold be beneficial to the market. The AMA, the MGMA and the AFP will send a letter to the Subcommittee that suggests how a database relationship could work between UPD and PECOS, for example. Guiding principles should be developed.It might be more useful to have a central portal for information input than a central database (CMS is moving in this direction for Medicare and Medicaid provider enrollment). Knowing whether provider portals interface with public and private entities was seen as critical. Not all data necessarily belongs in one place.

Registered health plans receiving enrollment information can reuse the data to ensure higher quality and less redundancy (CAQH report noted). Products in the market that assist with enrollment were mentioned. Legal ramifications of centralizing and offloading functions were enumerated, noting that federal and state licensing boards and the national data bank should be involved in these considerations. A question was posed about administrative simplification cost savings. Responses should be sent to Lorraine Doo.

SESSION II   Applicability of Standards to Other Insurance Types

Property & Casualty Keith Bateman, PCIAA; Jon Bergner, NAMIC
Workers Comp Greg Krohm, IAIABC; Bruce Wood, AIA; Lisa Wichterman, State of MN; Don St. Jacques, Jopari Solutions
Auto Insurance Susan Maynard, State Farm
X12 Margaret Weiker
WEDI Debbie Meisner
NCPDP Lynne Gilbertson


Minnesota’s change of state laws accounting for ICD-10 was clarified. States must recognize the need to change their laws to allow for updated code sets and standards. Those few states with no reference to ICD-9 in state administrative laws or regulations would not be affected. Within state regulations, ICD-9 is relatively narrowly applied; therefore, it would not be disastrous if administrative rules were not yet changed under new ICD-10 coding. While administrative rule changes can take a minimum of one-to-two years, such rules can be changed more quickly on an emergency basis.

A concern was raised about Medicare’s upcoming requirement of coding in ICD-10 for Section 111 reporting because many still struggle with ICD-9. In WEDI sessions, concerns have been raised about whether work comp must be converted from ICD-10 back to ICD-9; that is, will states be ready to accept ICD-10 in state reporting? Use of current code sets are being encouraged as much as possible. Significant differences (i.e., terms; workflows; relationships; and multiplicity of state regulations) between health care and property/casualty, workers comp and auto insurance were noted despite the fact that they all use the same providers. Issues with the current standards (e.g., health care bill; claim and claim payment; the acknowledgment) are important to consider, especially with regard to workers comp, auto insurance and property/casualty. It is encouraging to note that much consistent work is being done across the IAIABC, the associations and standard development organizations.

The eBilling concept was recommended, pushing forward use of electronic billing on the standards. More education is needed as is advocacy for the adoption of applicable HIPAA standards aligned with national standards. Advocacy is also needed for transactions applicable to property/casual, workers comp and auto insurance that align with national standards and adapt to the insurance lines. Formation of a policy advisory group was suggested to help craft more formal recommendations about the applicability of transactions to these three insurance lines.

Dr. Suarez asked if the Subcommittee was ready to recommend adoption of first report of injury in the industry. Several participants noted that a first report of injury goes from employer to carrier and the state agency rather than to health care providers. There are only three states that have a doctors’ first report of injury (shared with the state regulator, the insurance agent and sometimes the employer). The complexities of timing and electronic transactions related to workers comp were noted. No implementation guide for the first report of injury at X12 currently exists. Ms. Weiker disagreed with Dr. Suarez about whether transactions work, noting that they work with some workarounds and that a bridge strategy has been built and incorporated into 6020.

SESSION III   Transparency of Claim Edits, Publication of Plan Payment Rules, Standardized Forms for Audits

A. Claim Edits/Plan Payment Rules

National Correct Coding Initiative Niles R. Rosen, NCCI; Donna Schmidt, CMS; Shantanu Agrawal, CMS
Health Plans Chris Jagmin, Aetna
Providers Tammy Banks, AMA
Pharmacy Annette Gabel, NCPDP
HBMA Holly Louie, HBMA
Coders Rhonda Buckholtz, AAPC
Vendors Deb Strickland, Tibco
State Initiative Barry Keene, State of Colorado

B. Audits

Medicare RAC Audits Connie Leonard, CMS
Provider Perspective Mari Savickis, AMA
NCPDP Lynne Gilbertson


Results of the Colorado State Initiative were summarized, noting lexicon as an issue and the fact that nationally recognized sources are not as uniform as anticipated. Impact results will be available by December 2012 with implementation to begin in January 2013. Claims edits were defined as a subcategory of business rules.

Ms. Doo asked who in the group would participate in a group charged with developing two recommendations for change that could occur within a two-year timeframe. One participant thought that WEDI would be the place to conduct such a group because of its diverse parties and effectiveness, noting the need to involve coders and benefits experts. Another thought that WEDI would be effective for noncontroversial topics (e.g., modifier definition) but that the Secretary would need to convene a group for more complex issues (such as unifying code edit sets). The medical societies are important to include due to so much change in clinical technique and procedures and software vendors. Using public members such as Barry Keene was recommended as a resource that is needed to move forward.


SESSION I   Maintenance of Standards and Operating Rules

DSMO Margaret Weiker
CAQH/CORE Gwen Lohse
NACHA Jan Estep; Michael Herd
WEDI Jim Daley


The evolution of HIPAA since 2003 was reviewed. In a “perfect” world: standards would be updated every two years; a process would exist to adopt or change the standard in emergencies; and operating rules would address issues that standards don’t. In the current imperfect world, a new standard is being implemented as are operating rules. Do Subcommittee members want to see a defined implementation timeframe for future versions (presentationsindicate “yes” by some; “no” by others). A suggestion was made to ask the SDOs and the operating rule entity every two years about whether to move to a new standard.

In a “post attachments” world, many areas have potential. Clinical documentation relating to healthcare delivery is being mirrored. It will be possible to use the content of available attachments for the payment process.HL7 does a one-to-two-year draft standard for a live trial use of attachments with some sets of partners, although an increase in demand for changing that content is anticipated. An emergency fix process exists within X12 buta way to move errata out faster will provide industry with relief when an emergency fix is needed. The regulatory process is what slows down the process. Previous errata discussions have highlighted different perceptions of terminology (e.g., maintenance versus modification; catastrophic versus corrective).

A question arose about the minimal time frame needed to make even a one-byte change to a transaction. A suggestion was made to examine the change process and the SDO and its impact on vendors; and to test the change before implementation. It will be difficult to move to new standard versions until benefits to the industry are clear. A problem statement of vendor implementation should be clarified. Lessons can be learned from meaningful use. An overarching vision is needed for a continuous change process that includes incremental changes and varying timelines.

Because it is difficult to predict future change, a fluid or adaptive approach is suggested. Changes to standards and rules are not put into federal regulation in the financial services industry. Private sector rulemaking organizations write the rules, which are then incorporated into what is done via the federal government and treasury. EHR vendors are on one-year update cycles (for what can be planned) that must be installed for users to remain supported. Examples look at medical information that improves the payment process. A voluntary certification and testing challenge rests with administrative transactions (where contracts are not focused on updates), noting possible EHR analogies. Because vendors will not support new attachment types on old software versions, hospitals or providers need to stay up-to-date.

The HIPAA report to Congress stated that HIPAA is operating in an unanticipated environment with new sources and data needs. Do future challenges include conditional mandatory attachments for contingencies that address various purposes? A huge level of inefficiency exists because of required provider reporting, which relates to the issues of frequency and direction of change. Who is not at the table for these discussions? There are no good metrics for a starting point or ways to measure impact going forward. A study of the transition from 4010 to 5010 was suggested relative to what has and hasn’t worked; barriers; timeframe; possible improvements; coordination; and sequencing. The current timeframe for release of new operating rules and standards was summarized. In the past few years, there has been a “perfect storm” of IT initiatives that require resources of manpower and money.

It was noted that 6020 is the foundation for the next version of the implementation guides. During the public comment period for the 6020, it is important to give feedback (August 2012 publication date). The pharmacy industry will evaluate the changes and make recommendations to the DSMO. There are processes to help the industry survive between versions.

Public Comments

Jeanette Thornton (AHIP) stressed the need for the industry to work together to resolve claims edits standards issues in an open and balanced way, noting that state variations will not work. Further, she cautioned against a national database, recommending instead that the Subcommittee helps to create a marketplace for solutions based on common data standards. Questions centered on: what key data are needed across the provider enrollment process; how such standards can be used to create national utilities to achieve this end; and whether a process can be established that gets provider data to those requesting it while ensuring data ownership to those supplying data.

Because the same data are being used, Dan Rodes (AHIMA) thought it important to incorporate “what is happening here” with what the HIT Committees are doing, following ONC’s direction. Without coordination, the same data definitions are needed; as are consideration of implementation implications and the depth of the changes. Incremental updates were recommended for timeliness and flexibility. Mr. Peter Walker (AETNA) advocated for making the process for changing the standards easier, more timely and less expensive. A thorough review of all problems associated with 5010 was recommended.

Concluding Comments and Next Steps

Dr. Suarez noted the need for caution when making recommendations for that which is still evolving. An opportunity exists for new workgroups to focus on specific topics. A series of observations will be assembled and presented to the full Committee. Recommendations about process will be vetted through the Committee process. Specifically, recommendations about parts of Section 10109 and claims attachments should be ready for presentation tothe HIT Standards and Policy Committees by the first 2012 NCVHS meeting. The industry was asked to convey ideas about topics for 2012 hearings (which will include 5010 implementation; ICD-10; the transition to new operating rules in early 2013). A hearing suggestion about how entities track impact was made. A request was made for participants to send Dr. Doo, Dr. Warren or Dr. Suarez ideas for how to identify metrics, measures or impact on big implementations such as 5010.

Dr. Warren thanked participants and adjourned the meeting (no time mentioned).

To the best of my knowledge, the foregoing summary of minutes is accurate and complete.

/s/                                                                            March 1, 2012


Judith Warren, Ph.D., R.N.                                                       Date



Walter G. Suarez, M.D., M.P.H.                                              Date