Statement of the National Uniform Claim Committee
To the
National Committee on Vital and Health Statistics’
Workgroup on Quality
Presented by Jean P. Narcisi
September 14, 2004
My name is Jean Narcisi. I am the Director of Electronic Medical Systems for the American Medical Association (AMA) and Chair of the National Uniform Claim Committee (NUCC). It is my pleasure to appear today before the Workgroup on Quality of the National Committee on Vital and Health Statistics (NCVHS). I would like to thank you for the opportunity to testify.
Background:
The NUCC was formally organized in May 1995. It is designed to parallel the NUBC,
but for the non-institutional health care community. The NUCC replaces the Uniform
Claim Form Task Force, which was co-chaired by the AMA and CMS (formerly HCFA) and resulted in the development of the CMS 1500, formally called the HCFA 1500, a single paper claim form designed for use by all third-party payers. The NUCC continues to be responsible for the maintenance of the 1500 claim form. With the increasingly rapid transition of the health care community to EDI and the proliferation of data element definitions among various payers, it was essential that an organization such as the NUCC be established to maintain uniformity and standardization in these areas.
The NUCC was created to develop a standardized data set for use by the non-institutional health care community to transmit claim and encounter information to and from all third-party payers. It is chaired by the American Medical Association (AMA), with the Centers for Medicare and Medicaid Services (CMS) as a critical partner. The Committee includes representation from key provider and payer organizations, as well as standards setting organizations, state and federal regulators and the NUBC.
The NUCC was formally named in the administrative simplification section of the
Health Insurance Portability and Accountability Act (HIPAA) of 1996, Public Law 104-191 (P.L. 104-191) as one of the organizations to be consulted by the American National Standards Institute’s accredited Standards Developing Organizations (SDOs) and the Secretary of Health and Human Services (HHS) as they develop, adopt, or modify national standards for health care transactions. The NUCC was also named as one of the HIPAA Designated Standards Maintenance Organizations (DSMO) to maintain the HIPAA transaction standards. A DSMO Web site has been established to submit requests for changes to the HIPAA implementation guides. More information regarding the DSMO groups and the process for submitting change requests can be found at www.hipaa-dsmo.org
The NUCC completed the development and voted to approve the original version of the NUCC-Data Set (NUCC-DS) in 1997. The data set is designed to be technology and
architecturally-independent and is intended to apply to the claims and equivalent
encounters and COB transactions specified in the HIPAA. The original NUCC-DS was
constructed based upon the combined universe of fields included in the 1500 paper claim form, the Medicare National Standard Format (NSF), the NCVHS core data set and the ASC X12N 837 Professional Implementation Guide. The NUCC-DS has recently been updated to version 2.0 and it serves as a supplementary document to the HIPAA 837 professional implementation guide. It also includes a mapping and cross-reference to the 1500 paper claim form.
Candidate Recommendations:
I believe that only the following 4 of the first 8 candidate recommendations apply to a professional claim:
Candidate Recommendation 1 – Selected Laboratory Results;
Candidate Recommendation 2 – Selected Vital Signs & Objective Data;
Candidate Recommendation 6 – Start and end dates for Global Procedures;
Candidate Recommendation 8 – Reporting Functional Status Codes;
Michael Beebe will go into detail regarding the CPT Category II codes that are currently being developed by the AMA. However, I’d like to give you some brief background information in order to explain how I believe the candidate recommendations relate to CPT Category II codes. CPT Category II Codes for Performance Measurement are new codes that are intended to facilitate data collection by coding certain services and/or test results that are agreed upon as contributing to positive health outcomes and quality patient care. This category of CPT codes is a set of optional tracking codes for performance measurement. These codes may be services that are typically included in an Evaluation and Management (E/M) service or other component parts of a service and are not appropriate for Category I CPT codes. The use of tracking codes for performance measures will decrease the need for record abstraction and chart review, thus minimizing administrative burdens on physicians and survey costs for health plans. Attached as Appendix I is additional information related to the Category II CPT codes.
I believe that Candidate Recommendation number 1- Selected Laboratory Results and Candidate Recommendation number 2- Selected Vital Signs could currently be reported using CPT Category II codes on a 1500 paper claim form or an electronic 837 transaction without changing the NUCC-DS, the 1500 form or the electronic transaction. However, laboratory test results and the vital signs may not be available to the coders when the claims data are being collected and reported to a payer. In addition, the Category II codes are not currently being used by physicians and payers for collecting this type of data. Providers and payers would need to standardize their data collection and reporting methodologies using the CPT Category II codes on paper or electronic claims.
I believe that Candidate Recommendation number 6 – Episode start and end dates for services billed using global procedure codes could also be collected without modifying the NUCC-DS, 1500 form, or the electronic transaction. However, the billing instructions to providers would need to be standardized for procedure start and end dates with services included in selected global procedures. The NUCC could develop the standardized billing instructions and the appropriate codes and guidelines for global procedures could be enhanced in CPT. However, they would need to be adopted by CMS, Medicaid agencies, and private payers in order to be implemented nationally. Pilot testing is essential to determine that the codes will work with the current standards.
Candidate Recommendation number 8 – Reporting Functional Status Codes in a standard transaction could possibly be reported in the current 1500 paper claim form or electronic 837 transaction. The AMA will begin working early next year with the National Library of Medicine to develop mappings of CPT to SNOMED CT and LOINC. Functional status codes could then possibly have a cross-reference code in CPT similar to what has been developed for the performance measurement sets. This would allow for the functional status to be reported using current reporting mechanisms.
Standards for exchange of patient data for quality measurement and improvement are necessary. However, electronic data transfer to organizations that oversee quality measurement data need to be consistent with standards that are already mandated for providers and payers such as the HIPAA standards. Quality measurement data standards need to support “dual use” of privacy, security, identifiers, messaging formats and data content of the HIPAA administrative simplification standards.
Collection of patient data should be seamless for providers. Therefore, the cost of implementation related to standards and the burdens on the provider need to be considered when developing recommendations. As you know, HIPAA was signed into law in 1996. We all had high expectations that it would truly cut down on administrative burdens and simplify the way providers reported patient data to third-party payers. However, more than eight years after the law was signed, all the regulations have still not been finalized.
I believe that the most effective and efficient way to move forward would be through pilot testing of the CPT Category II codes with the current paper claim form and electronic transactions to determine if the 4 candidate recommendations I’ve mentioned will provide appropriate data for evaluation. Vendors should also be factored into the testing because physicians must rely on their vendors to provide them with the tools necessary to comply with data collection and reporting. If, after testing, it is determined that changes need to be made to the HIPAA standards, this could be done through the DSMO process. However, any changes to the standards and implementation guides would certainly delay implementation.
Regarding your questions related to the collection of race and ethnicity – race and ethnicity are not collected on the paper claim form or the HIPAA electronic 837 transaction. I believe the elements are part of the 837 standard, but they are identified as “not used” in the HIPAA implementation guides. I believe that if the 837 Implementation Guide were updated to include these data elements, it would take a very long time to implement. In addition, I believe the collection of these data would be very burdensome for the provider
This information would more likely be collected on an enrollment transaction and the following note is currently listed in the enrollment implementation guide.
“This data should only be transmitted when such transmission is required under the insurance contract between the sponsor and payer and allowed by federal and state regulations. This element is NOT USED when the member identified in the related INS segment is not the subscriber. See section 2.7, “Coverage Levels and Dependents”, for additional information.”
Last year a DSMO change request was submitted through the DSMO process regarding developing some type of announcement or directive, which would require that definitions be developed so that the race and ethnicity codes would be used consistently in a HIPAA enrollment transaction.
The DSMOs recommended that the commenter direct the request to the Office of Management and Budget (OMB) to seek clarification on the use of their coding schema. The DSMOs also indicated that the use of the HIPAA internal codes are generally self-reported and are based on codes historically utilized for the United States census. Furthermore, the DSMOs determined that the development of definitions for these codes were outside the scope of the standard as the data elements are utilized in other industries besides healthcare. Since definitions are not provided in the implementation guide or X12 standards, it was suggested that the trading partners come to a mutual understanding of what each code represents as it relates to the questions presented above.
Race and ethnicity are not typical data elements collected by providers of healthcare. Standards for the collection of data from health care providers that permits valid comparisons of similar cases among similar health care providers are important. Comparable and accurate patient data will enhance the value for clinical research, epidemiological purposes and assist organizations overseeing performance measurement. However, efforts to enhance comparability must not detract from the fundamental clinical purpose of health care services, which should focus first and foremost on the needs of patients, their physicians, health care professionals, and the institutions and facilities in which patients receive their care.
Therefore, if the race and ethnicity data are available in the enrollment databases, the administrative claims data received from the providers would in some way need to be linked to the appropriate data in a health plans’ enrollment database in order to identify comparisons among racial and ethnic groups.
Thank you for this opportunity to present my views as Chair of the NUCC and Director of Electronic Medical Systems for the American Medical Association. I would be pleased to respond to any questions that you might have.
Appendix I
The CPT Editorial Panel established a Performance Measures Advisory Group to assist in the development of these codes. These tracking codes have been developed with input from the national medical specialty societies, the National Committee on Quality Assurance, the Joint Commission on Accreditation of Health Care Organizations, the Agency for Health Care Research and Quality, the Centers of Medicare and Medicaid Services, and the American Medical Association.
Clinical Performance Measurement Sets are tools that have been developed by the AMA to support physicians in their efforts to enhance the quality of patient care. These tools, developed by physicians for physicians, consist of clinical performance measures derived from evidence-based clinical practice guideline recommendations and an accompanying data collection flow sheet. The performance measurement sets can be used by physicians to gather data from their own practice, measure their own level of performance, and, ultimately, enhance the care of their patients. CPT Category II codes are being or have been developed for the following performance measurement sets:
- Asthma
- Chronic Stable Coronary Artery Disease
- Diabetes – Adult
- Heart Failure
- Hypertension
- Major Depressive Disorder
- Osteoarthritis of the Knee
- Prenatal Testing
- Preventive Care and Screening: Screening Mammography, Adult Influenza Immunization, Colorectal Cancer Screening, Tobacco Use, and Problem Drinking
For more information regarding CPT Category II codes go to: