ATTACHMENT SIG

MEETING MINUTES

ST. LOUIS, MO. -- SEPT 12 - 13, 2000

AGENDA

TUESDAY, SEPT 12, 2000 - MORNING SESSION

  1. SIG NAME CHANGE
  2. MOU PROCESS UPDATE
  3. MEDICAID PRESENTATION

TUESDAY, SEPT 12, 2000 - AFTERNOON SESSION

  1. ACKNOWLEDGMENT FOR HL7 MESSAGES WITHIN X12 275 BIN
  2. DMERC ATTACHMENT UPDATE
  3. PRE-AUTHORIZATION/REFERRALS ATTACHMENT UPDATE
  4. HL7 / HIPAA TASK FORCE

WEDNESDAY, SEPT 13, 2000 - MORNING SESSION

  1. CONGRATULATIONS TO MARIA WARD
  2. HOME HEALTH ATTACHMENT UPDATE
  3. NEW ATTACHMENT TYPES

WEDNESDAY, SEPT 13, 2000 - AFTERNOON SESSION

  1. CHANGES TO HL7 SPECIFICATIONS PRIOR TO NPRM
  2. WORKING TOWARD HL7 STANDARD VERSION 3
  3. ACTION ITEMS
  4. NEXT MEETING LOGISTICS

TUESDAY, SEPT 12 – MORNING SESSION

ATTENDEES: Steve Barr, Mary Lynn Bushman, Gale Carter, Laura Culbertson, Dave Feinberg, Sheila Frank, Jim Leach, Fran Lettko, Chuck Meyer, Conny Nichols, Dan Pollack, Nancy Sloan, Chris Stahlecker, Maria Ward, Margaret Weiker, Sandy Weiler, JoAnne Weingarth, Karen Strong, Jeff Seybold, Suzie Burke-Bebee, Catherine Schulten, Helen Fallahi, Tammy Dugan

  1. SIG NAME CHANGE

The new name for the Claims Attachment Special Interest Group (CASIG) was approved by the Technical Steering Committee (TSC). This SIG is now officially the “Attachment Special Interest Group” (ASIG) since the charter of the group has changed to include attachments other than those related to claims.

  1. MOU PROCESS UPDATE

The six organizations involved in the Memorandum of Understanding (MOU) have been designated as the Designated Standards Maintenance Organizations (DSMO) in the final rule issued on August 17, 2000. Margaret Weiker (representing NCPDP) is the Chair, Maria Ward (representing HL7) is the Vice Chair, and NCPDP will be assuming the role of Secretary.

Washington Publishing Company (WPC) has designed and will be maintaining the DSMO website This site will fulfill two objectives.

  1. Change Request System – where a user can make a request to change the implementation materials named in HIPAA.
  2. Frequently Asked Questions – where a user can submit a question & answers will be maintained online.

The HL7 representatives to the DSMO are looking for feedback from HL7, and the Attachment SIG regarding how to handle HL7 related issues that are currently being informally passed on to ASIG co-chairs. Under the MOU agreement, HL7 is only responsible for supporting change requests, not FAQs. However, HL7 also feels that it is appropriate to answer questions specifically related to HL7. One issue discussed was how to handle questions not specifically related to HL7, when the requestor may not realize that they are asking the wrong organization(website guides the requestor to select one of the six organizations to ask their question of). After brief discussion, the ASIG agreed that instructions are necessary to direct requestors to the right organization and/or inform of the types of questions HL7 will answer. Additionally, we agreed that disclaimers are necessary for the FAQ so that the DSMOs do not have any liability issues related to the answers provided. We recommended an explicit disclaimer that the answers provided are not meant to be construed as consulting services. Margaret Weiker will relay this back to the DSMO Steering Committee.

Additionally, questions related to HIPAA and HL7 are beginning to filter down to ASIG co-chairs, regardless of whether the question is related specifically to attachments.. Cochairs are seeking clarification as to what the ASIG’s role is as far as HIPAA goes. The consensus within the ASIG was that the ASIG should answer questions related to attachments, and another committee should be formed to address more broad based HL7 - HIPAA issues/questions. This committee should only facilitate and coordinate issues among the HL7 chapters, and report back to the Board. However, the committee will likely need to include representatives from the ASIG. There has already been preliminary discussion of such a Board sponsored Task Force/ Committee by several members of the Board.

  1. MEDICAID PRESENTATION

Sheila Frank (HCFA) presented information regarding the Medicaid’s recent involvement in HIPAA related issues. A group called the National Medicaid EDI HIPAA Workgroup (NMEHW) has been formed to address Medicaid’s needs. The Chair of this group is Lisa Doyle from Wisconsin Medicaid. Over 40 states currently participate in this volunteer workgroup. Some key points are as follows:

PROCEDURE CODES
  • One of the biggest issues that Medicaid faces is the number of local procedure codes that they use. Over 33 states submitted templates containing 20,000 local codes. California Medicaid volunteered to consolidate and map these local codes to the standard code sets; any new code requests will be forwarded through the appropriate organizations.
ATTACHMENTS
  • Gail Lowrey of Mississippi Medicaid is the Chair of Attachments under the NMEHW
  • 25 states participated in an effort to identify Medicaid’s need for attachments. They have identified 553 attachment types! However, Sheila Frank has assured the ASIG that many of these are duplicates. A committee is currently in the process of categorizing these attachment needs. The process of categorizing will also include a review of the 6 currently defined attachment types to verify if Medicaid needs are met.
  • The categories which Medicaid is using for consolidation are:

Sterilization, Hysterectomy, Abortion, TPL, Eligibility, Dental, EPSDT, Transportation, Free Form Text Reports, Medical Necessity, Justification, Exception to Policy, X-rays, and NOC.

  • The results of the categorization efforts, and review of the 6 existing attachment types will be presented at the X12 conference in October.
  • Sheila requested assistance by ASIG in participation of Medicaid’s efforts to develop attachments to meet their needs. ASIG informed that Medicaid representation would need to come to ASIG and request to begin work on a specific attachment type – with that representative taking the lead in the development. The ASIG will provide guidance and support in the development.
  • Sheila informed that the Sterilization attachment would be requested first. However, she will have to find out whether an electronic signature will be necessary, or whether an indicator for “signature on file” will be sufficient.
  • Medicaid is working on attachments for Prior-authorization / Referrals with the X12N 278 workgroup. Stacey Barber of North Carolina Medicaid is the Chair of Prior Authorization under the NMEHW. A new list of LOINC requests will be ready for submission to the ASIG at the January 2001 HL7 conference. In addition, Medicaid will be meeting with the X12N 275 workgroup at the October 2000 X12 committee meeting to discuss their needs.

For a copy of Medicaid’s entire presentation, please contact Sheila Frank via email:

TUESDAY, SEPT 12 – AFTERNOON SESSION

ATTENDEES: Steve Barr, Mary Lynn Bushman, Gale Carter, Laura Culbertson, Dave Feinberg, Helen Gurevich, Jim Leach, Fran Lettko, Chuck Meyer, Conny Nichols, Dan Pollack, Nancy Sloan, Chris Stahlecker, Maria Ward, Margaret Weiker, Sandy Weiler, JoAnne Weingarth, Karen Strong, Jeff Seybold, Suzie Burke-Bebee, Catherine Schulten, Helen Fallahi, Tammy Dugan

  1. ACKNOWLEDGMENT FOR HL7 MESSAGES WITHIN X12 BIN

Currently, there no mechanism for acknowledging the HL7 message contained within the X12 275

BIN segment. Because this issue will likely be submitted as a comment to the NPRM, the ASIG needs to be prepared to address it.

Although the acknowledgments are not mandated under HIPAA, the opinions on the need for an acknowledgment were mixed. Some felt that whatever data is in BIN02 (in this case the HL7 segments used to convey attachment information) is just data content – not subject to syntax checking. They felt that the application level would have to handle the ‘editing’ of the data content; syntax was not an issue. However, others felt the need for syntax checking (based on trading partner agreement) since the particular data content being used (i.e. an HL7 message) does have syntax requirements. If there is a problem with the syntax, and the message cannot be translated, it would never get to the application level. Consequently, if no syntax checking takes place and the translation was able to occur, a messaging error left unedited couldcreate a bigger problem at the application level. In addition, this acknowledgment would be beneficial for provider and vendor testing – especially those who have never utilized HL7.

ASIG agreed to at least be prepared to address this future NPRM comment; therefore, a number of options were briefly explored.

HL7 has two levels of acknowledgment – the NAC and ACK. However, the NAC is the more common acknowledgment. The acknowledgment only informs of a problem with the message. It does not pinpoint the actual problem. Some felt that this message, without the detail, would be worthless. Others felt that this message would be better than nothing; in this case, there would at least be an immediate trigger for the need for manual research of the problem before passing the data on to the application system.

When syntax checking takes place, the message is typically captured to an error log. Therefore, it was thought that perhaps this error log could be sent along with the HL7 ACK/NAC if enveloped by an X12 transaction.

A vendor comment was also made that the acknowledgment created may depend on the method of translation. For example, if translation software can handle translating one continuous string of data (X12 & HL7 mixed), a different acknowledgment may be triggered than if the translation needed to occur one part at a time (i.e. X12 first, then HL7 message second).

With all of these uncertainties, the group identified the possibility of the following, which would all need to be looked into further

  • HL7 ACK/NAC acknowledgment independent of an X12 envelope
  • HL7 ACK/NAC enveloped by an X12 transaction – perhaps a new implementation of the 864 or 102 transactions
  • a new implementation of the 277 transaction
  • the 997 transaction as best it can be utilized (expand the error codes, etc.)

Although it was agreed that this is not really an X12 issue, a group of ASIG members (Gale Carter, Laura Culbertson, Mary Lynn Bushman, Steve Barr, Dave Feinberg and or Chuck Meyer) will seek the opinion of X12 Architecture during the X12 conference in October 2000.

  1. DMERC ATTACHMENT UPDATE

Because Certificates of Medical Necessity (CMN) are not included in the X12 278 transaction, which was intended to be used for pre-authorization by Durable Medical Equipment Regional Carriers (DMERC), DMERCs will be using TXT (text) segment in the 278 to answer CMN questions. In the mean time, Gale Carter has been in the process of developing a DME attachment based on the OMB approved form. This attachment to an X12 278 pre-certification will accommodate CMN questions. Once completed, we expect that the attachment will likely be adopted under HIPAA. The process of identifying all CMN questions has been completed. The next step will be for Gale and Clem McDonald to discuss LOINC codes and then for the completed attachment recommendation to be presented to the ASIG for approval.

  1. PRE-AUTHORIZATION/REFERRALS ATTACHMENT UPDATE

So far, there has been one conference call regarding development of pre-authorization / referrals attachment. The existing X12N 275 guide is being used as a basis for a new 275 implementation guide to accommodate the X12 278 workgroup needs. The first draft of this new implementation guide should be ready for distribution at the October X12 conference.

  1. HL7 / HIPAA TASK FORCE

The HL7 Board created a Task Force to advance HL7 in the world of HIPAA. John Quinn, Freida Hall, and Chris Stahlecker are current participants. They are soliciting participation and agenda items for issues to be addressed. So far, there has only been discussion on activities such as: education, advancing HL7 along with the HIPAA transactions, and linking the content of the left side of the Reference Information Model (RIM) to the HIPAA transaction sets for ease in implementation.

ASIG participants pointed out that the linking of the HL7 content of the RIM is already underway by the Dept of Defense and HCFA. Vocabulary amongst Standard Development Organizations (SDO) is being normalized by entry into a central registry. This registry is named the United States Health Information Knowledge Base (USHIK), and is for all data – not just data under HIPAA. Mayo will become the host of this registry. HL7 has already provided their Reference Information Model (RIM) for entry; therefore, ASIG felt no need for HL7 Task Force to champion any similar effort. The USHIK registry is still in draft, but can be found under:

If anyone is interested in participating on the HL7 / HIPAA Task Force, please contact Chris Stahlecker via email:

WEDNESDAY, SEPT 13 – MORNING SESSION

ATTENDEES: Steve Barr, Mary Lynn Bushman, Gale Carter, Laura Culbertson, Dave Feinberg, Helen Gurevich, Jim Leach, Fran Lettko, Conny Nichols, Nancy Sloan, Maria Ward, Margaret Weiker, Sandy Weiler, JoAnne Weingarth, Nancy Wilson-Ramon, Karen Strong, Jeff Seybold, Catherine Schulten, Tammy Dugan, Judy Audin

1. CONGRATULATIONS TO MARIA WARD

Maria Ward was presented with a Volunteer of the Year Award during the HL7 Annual Business Meeting prior to the ASIG meeting this morning. Congratulations, Maria!

2. HOME HEALTH ATTACHMENT UPDATE

During the development of the Home Health Attachment type, the discovery was made that the Home Health Industry uses many local codes (HCPCS Level 3 codes) that will need to be replaced with National HCPCS codes. The Home Health Attachment leaders drafted a letter to the HCPCS committee petitioning for National Codes; however, this letter still requires wordsmithing.

ASIG discussed whether this is really an attachment issue. Some felt that if no National codes were assigned, ASIG would need to support via the Home Health Attachment type. Others felt that the issue pertains only to billable services – which would never be attachments. Consensus was reached that the Home Health Industry should be responsible for submitting this request themselves, without HL7 ASIG involvement. The question was then raised as to whether HL7 ASIG should send a letter supporting the Home Health Industry’s request. The decision was made that this is outside of the scope of the ASIG responsibilities.

Some ASIG members noticed many of the requests already have NDC codes. Co-Chairs will send a message to the Home Health Attachment leads to inform that the local codes issue is outside of the scope of the ASIG. They will also inform, per the Final Rule, local codes must occur more than 50 times per year; else, Not Otherwise Classified (NOC) codes should be utilized.

The attachment templates created based on the HCFA 485, HCFA 486, and OASIS data were distributed, but not discussed or reviewed since the key participants in the Home Health attachment development were not able to attend this conference.

3. NEW ATTACHMENT TYPES

ASIG briefly discussed which attachment type should be worked on next, if any. A motion was made to NOT begin work on any Medicaid attachment types until the request is submitted through the MOU process. The motion was seconded, and none opposed.

There was agreement among ASIG that the development of a “process doc” would prove beneficial in providing guidance to those leading the development of new attachment types. There was much discussion regarding whether these steps were necessary regardless of whether request was submitted via DSMO process or not. Decision was made to first draft the necessary steps; these steps can then be ordered or identified as to whether they apply to requests submitted via the DSMO process. A summary of necessary steps within the process was created:

“Attachment Development for Dummies”

Background Material – Include having them look at existing transactions. This information may be in a previous electronic standard.

Attachment Template and Instructions for Completion including Example

1.What is the purpose or need of the data element(s)

2.Gather the Attachment data and any supporting documentation including paper forms or source documents

3.Bring completed Attachment Spreadsheet to the ASIG

4.Send completed spreadsheet with Outreach notification

5.Workgroup is formed and Teleconferences scheduled

  1. Consensus on Data Elements needed
  2. Final Spreadsheet is sent to the LOINC Consortium
  3. Booklets created
  4. HL7 ASIG approval process

ASIG agreed that when requests begin, the priority would need to be addressed with the HL7 Steering Committee.
WEDNESDAY, SEPT 13 – AFTERNOON SESSION

ATTENDEES: Steve Barr, Mary Lynn Bushman, Gale Carter, Laura Culbertson, Dave Feinberg, Jerry Kirchner, Jim Leach, Fran Lettko, Clem McDonald, Chuck Meyer, Conny Nichols, Dan Pollack, Nancy Sloan, Chris Stahlecker, Maria Ward, Margaret Weiker, Sandy Weiler, JoAnne Weingarth, Nancy Wilson-Ramon, Karen Strong, Suzie Burke-Bebee, Catherine Schulten, Helen Fallahi, Tammy Dugan, Judy Audin, Michelle Williamson

1. CHANGES TO HL7 SPECIFICATIONS PRIOR TO NPRM

Clem McDonald has identified a number of items relevant to the overall improvement of the attachment recommendation, as well as changes to improve specific attachment types. The key discussions focused on the following points: