ATTACHMENT SIG

MEETING MINUTES

MINNEAPOLIS, MN. – MAY 07 – 10, 2001

AGENDA

MONDAY, MAY 07, 2001 - MORNING SESSION

1. HL7 BALLOT FOR CLAIMS ATTACHMENTS

  1. USE OF IMAGES IN THE BIN

MONDAY, MAY 07, 2001 - AFTERNOON SESSION

1. DSMO ACTIVITY

  1. UPDATED DSMO PROCESS FLOW DOCUMENT

TUESDAY, MAY 8, 2001 - MORNING SESSION

1. NMEH (NATIONAL MEDICAID EDI HIPAA WORKGROUP) UPDATE

  1. UPDATE ON DME ATTACHMENT

3. UPDATE ON DENTAL ATTACHMENTS

  1. UPDATE ON ABORTION, STERILIZATION, HYSTERECTOMY ATTACHMENT
  2. UPDATE ON OTHER MEDICAID ATTACHMENTS

TUESDAY, MAY 8, 2001 - AFTERNOON SESSION

  1. PROCESS IMPROVEMENT DISCUSSION

WEDNESDAY, MAY 9, 2001 – MORNING SESSION

1. MEETING LOGISTICS / AGENDA FOR OCTOBER CONFERENCE

  1. SOLICIT VOLUNTEERS FOR UNFINISHED PROJECTS
  2. PRESENTATION ON DIGITAL SIGNATURES

WEDNESDAY, MAY 9, 2001 – AFTERNOON SESSION

1. HOME HEALTH ATTACHMENT

  1. X12 278 WORKGROUP ATTACHMENTS
THURSDAY, MAY 10, 2001 – MORNING SESSION
  1. RELMA PROGRAM PRESENTATON
  2. VOTE ON VERSION CHANGE OF HL7 IMP GUIDE
THURSDAY, MAY 10, 2001 – AFTERNOON SESSION

1. REVIEW LOINC BOOKLETS

MONDAY, MAY 07 – MORNING SESSION

  1. HL7 BALLOT FOR CLAIMS ATTACHMENTS

Chuck Meyer and Wes Rishel advised the SIG on the ballot process for the booklets which opens in May. Passing the ballot requires every single comment be dealt with. The categories follow:

Yes – with modification
No – Non-Pervasive
Yes – Later version / Implementation

If a document has substantive change it is then balloted again. Several large blocks vote “No” it is passed to a sub-committee of odd numbered committee members. It then must have 70 % of “Non-Abstaining” voting pool to pass. The Chairs can decide when to close the ballot.

Also discussed was the work of the Templates group. Basically they reviewed the work product of the ASIG and now base recommendations the format started by the ASIG.

  1. USE OF IMAGES IN THE BIN

There seems to be a misconception that those who have never used HL7 will need to begin using HL7. A more accurate statement is that only a few parts of HL7 structure would need to be coded in the currently existing application systems.

The attachment types can be logically categorized into “fixed” & “variable”. The fixed types are those such as Ambulance, which can only include the LOINC codes that are listed in the booklet. The variable type are those such as Laboratory, which can include LOINC codes from the entire LOINC listing. The difference between the booklets that were previously published and the ones being discussed this week is not the “fixed” vs. “variable” concept, but rather, that with certain attachments where text is allowed, images will also be allowed. The provider would be the one determining whether the type being sent is text or image of text. Payers would need to be able to accept either type.

Of all the attachment types, Lab is the one that would most likely be retained for the longest period of time in the provider’s system. Wes is hearing that providers do not want to send payers the entire set of information if all they need to give is one piece; & that MSK must be the minority. There is an increased interest in images due to the medical record process being manual since keyers take paper home to key from. The use of images would reduce paper and increase security. In the future, there will be the issue of educating keyers to key LOINC; although it was noted that the proof of concept project determined that the other codes sets were unusable.

There are state mandates which say that only medical record information can be released. However, Wes questions what constitutes medical records. Can MSK’s legal department say that the data from the other places (before being ‘final’) be part of the medical record which can be released?

The outcome of the previous decision to allow for images was to comprise the stance on how to handle medical records. We (ASIG) need to take a position on what to do. If free form text is allowed, then medical record images should also be allowed. Wes and cochairs put together a proposal listing the options on how to handle images. This document needs to be revised to constitute a solid recommendation. There was a question as to what the acceptable quality of the image would be. Wes determined that if the quality of the image is as good as the quality of a good fax, then that should be acceptable. The discussion turned to the need for JPEG @ 200 pxls per inch. It was decided that since we’re only currently discussing document images (images of text), as opposed to xrays, etc., that only CCITT Group 3 is necessary. The ASIG is only going to address one general wayt to handle images within the context of the 6 already established attachments. The rest of the image types are to be handled as new attachment booklets are developed. Therefore, there is no need color yet, either. It was noted that the Pre-Cert/Referrals attachments which HL7 opted in to develop will likely see the need for color images before any claims related attachments are developed.

There will be some changes to the booklets based on Wes’s document – there needs to be language in the beginning of each booklet that will point to this ‘white paper’ by listing a URL link to the document.

MONDAY, MAY 07 – AFTERNOON SESSION

  1. DSMO ACTIVITY

Dave Feinberg provided an update on the X12 DSMO activities. He indicated that X12 is continuing with the fast track process. They have built addenda to the implementation guides to accommodate 42 changes. These changes were ones that had been agreed upon by the DSMO committee as “Category A” changes – ones needed in order to meet compliance. There is now a 30 day open comment period on these changes. There will be informational forums at the June X12 conference to discuss the comments. The addenda will then be turned over to HHS for the NPRM process. After June, the X12 activities will revert back to the regular X12 process cycle (which is up to version 4050), and only act as a support to HHS for questions.

There were quite a few questions posed to Dave and the others involved in the DSMO process; the questions & answers are as follows:

Q: How will addenda items & other changes become version 4050?

A: Addenda items & all others that didn’t consitute necessity into the addenda(s) will be open for discussion in X12 workgroups when building the 4050 guides.

Q: Will the DSMO website become more user friendly?

A: The website has no funding. The website will not likely be enhanced unless some entities provide monetary support.

Q: Will people be ‘allowed’ to ask and/or argue the same points over & over again in the future?

A: All items have been categorized; however, anyone can comment on anything through the NPRM process. There is really no way to ‘disallow’ the same request to be entered into the website, except to repeatedly deny the request.

Q: What is the “appeals” protocol among the DSMO groups?

A: In cases where DSMO groups don’t all agree 100%, they can “appeal” & ask for industry input.

Q: Where can the list of categories used by the DSMO groups be obtained from?

A: They will be included in Margaret Weiker’s testimony at the end of May.

Q: Can the 275 version compatibility with other X12 guides be a topic for discussion at the WG9 sessions during the X12 conference in June?

A: Yes.

Maria Ward provided an update on the DSMO activities as they relate to HL7. She informed that, as it stands today, there are no DSMO requests for new attachments. However, the X12 278 group has identified a deficiency with their implementation guide, and HL7 opted in to develop an attachment to meet their needs. NOTE: This will not be a HIPAA guide, since it is not a CLAIM attachment. Maria recommended joining the HL7 listserv to stay in tune with the HL7 activities related to any DSMO requests.

The only other item that HL7 opted in to create XML representation for all guides. This request originated as a business need for pharmacy; however, NCPDP did not opt in. X12 has already developed name spaces, schemas, etc. HL7, however, does not see a need to develop this for HL7 since it was a business need for pharmacy. The HL7 recommendation will be to develop a collaborative effort with the other SDO’s to figure out a solution to the request, but not under the DSMO process.

  1. UPDATED DSMO PROCESS FLOW DOCUMENT

The ASIG continued work on finalizing the HL7 ASIG DSMO visio flow document. Since group was still unable to finalize during regular workgroup session, Mike volunteered to complete this flow document.

TUESDAY, MAY 8, 2001 - MORNING SESSION

  1. NMEH (NATIONAL MEDICAID EDI HIPAA WORKGROUP) UPDATE

Penny Sanchez gave an update on recent & upcoming Medicaid workshops/demonstrations. HCFA had contracted with some of the Medicaid’s to hold a National Medicaid HCFA HIPAA Conference in Baltimore this past April. This conference was the forum to discuss HIPAA implementation with Medicaid community. One of the demonstrations presented during the conference was the “HIPAA Compliance Concept Model”. This model includes the MCIM (Medicaid Information Model) which is the model of the Medicaid subsystem components of a management information system. This Medicaid Information Model is a browser-based application which is a centralized repository for HIPAA information. This model is also being presented this week at the Government SIG. For more information, look to the HCFA Medicaid website,

2. UPDATE ON DME ATTACHMENTS

Gale Carter gave an update on the status & evolution of the DME attachments. Gale provided a handout containing the following information:

Status of DME Attachments

The evolution of the DME Attachments is as follows:

Originally the DME Attachment Spreadsheet covered the OMB DMERC Certifications for the following:

Hospital Beds, Support Surfaces, Motorized Wheelchairs, Manual Wheelchairs, CPAP, Lymphedema Pumps, Osteogenesis Stimulators, TENS, Seat Lift, Mechanism, Power Operated Vehicle, Immunosuppressive Drugs, External Infusion, Parenteral Nutrition, Enteral Nutrition, Oxygen

I had received comments last year from a few Medicaids including Montana and Mississippi and had included them in the CMN spreadsheet and created an Additional DME Spreadsheet which includes:

General DME Certification

Augmentative Communication Devices

EPSDT Nutritional Services

Orthotics and Prosthetics

Blood Glucose Monitoring System

The Home Health Attachment group reviewed that two spreadsheets and it was determined that the Home Health Attachment would be for the care given and a payer would use the DME attachment for additional information on supplies or equipment.

The two spreadsheets were sent out again to the Medicaids again in March and comments were received from the following States: Ohio, Wisconsin, Utah, New Jersey, Oregon, California, Minnesota, Washington, Florida, Virginia, West Virginia

We are at the point that the Medicaids on an attachment conference call last week, agreed to look at the certifications one last time and any states that had not responded would do so as quickly as possible.

Penny and I will setup conference calls to go over the comments and get the spreadsheets finalized for a final review and comment. (end of handout)

Gale indicated that the HL7 booklet would be the same if using the HL7 message in a 275 transaction for precertification as it would for using the HL7 message in a 275 transaction for a claim attachment. Others questioned whether this would be OK. The group felt that it would, because if a payer doesn’t do pre-certs, then they do not have to use the 278/275/HL7 guide.

There was a question as to why the X12 275 transaction was even necessary. Group members provided a brief background on the concept. Chris Stahlecker will send her previous write-up on this issue to the ASIG listserv.

Another group member questioned whether the definition of DME is based on state or federal definitions. The DME attachments were based on Federal definitions, however, it is known that there are some items listed, such as EPSDT, that are not really DME. Gale indicated that EPSDT was going to be it’s own attachment booklet. If something is not really supposed to be categorized as DME, it will not really impact anything – it’s just a matter of scope of what Gale & the others in the group should be focusing on.

The next steps for the DME workgroup are to draft the outreach letter, compile the outreach audience, & establish conference calls with industry input.

If anyone is interested in participating on the DME conference calls, please contact Gale Carter for more information ().

  1. UPDATE ON DENTAL ATTACHMENTS

Jeff Seybold provided an update on the dental attachments needed for Medicaid. There are multiple dental attachments needed, but the Periodontal attachment is the priority. Dental claims need prior-authorization, but the X12 278 guide doesn’t meet the needs (i.e. the 278 guide doesn’t include the correct language). There is a difference between Pre-determination and prior-authorization. Pre-determination is on the provider’s behalf – to find out what payment liability exists. Prior-authorization indicates medical necessity on behalf of the payer, but does not guarantee payment. The 837 Dental implementation guide will be used for Pre-determination, not Prior-authorization. Therefore, there is a need for dental attachments for prior-authorization. However, there is no current need for images – only codified data. Jeff mentioned that the needs could be codified as an external code list & used with the 837, but that there are so many that it would make the 837 a nightmare.

Jeff will be sending a list of contacts to HL7 cochairs for dental related outreach to be included in the HL7 ASIG centralized database.

Because Jeff had so many positive things to say about developing this potential attachment, he will also put together a bullet point document describing the historical activities as a “success story” to be used for a template for crafting new attachments.

When the dental group is more comfortable with the basis for the attachment, they will then begin the steps to do outreach, and conference calls with the industry experts above & beyond the Medicaid group.

It was noted that HL7 has been sponsoring ASIG conference calls up to this point, but that we need to make sure that the more sub-groups we develop, the more sponsors we’ll have for the calls. HL7 cannot absorb the cost for all of the calls in the future.

  1. UPDATE ON ABORTION, STERILIZATION, HYSTERECTOMY ATTACHMENT

Penny Sanchez provided an update on the Medicaid activities for these types of attachments. The outreach letter for these attachments is ready to go. Penny questioned whether the ASIG felt use of the word “abortion” in the outreach letter was appropriate. Most felt that the letter could be more general, but that the actual attachment would need to name the specific elements that it would be used for. Penny is envisioning having one attachment for “consent for services”, with specific subcategories for Abortion / Sterilization / Hysterectomy – such as was done with the Rehab attachment & it’s different ‘disciplines’.

Signatures are still a requirement on these attachments.

The goal of the Medicaid group is to have the data analysis begin in July 2001 & to be complete (with exception of the signature issue) before the next HL7 conference. There will be approximately 1-2 calls per week.

The final outreach letter and list of industry contacts will be given to Maria Ward, who will pass on to HL7 Headquarters.

  1. UPDATE ON OTHER MEDICAID ATTACHMENTS

There are currently three subgroups in NMEH working on attachments:

  1. Dental
  2. Claims
  3. Prior Authorization

The next priority attachment types for Medicaid will be: EPSDT, Long Term Care, Eligibility, and Third Party Liability.

The Medicaid group is also preparing for the NPRM to be released – they will be providing comments to the NPRM.

Penny has been giving attachment presentations – her presentation should be on the EDS website. On a related note, the attachment presentations that Maria Ward gave at WEDI Conference should be on the WEDI website.

TUESDAY, MAY 8, 2001 - AFTERNOON SESSION

  1. PROCESS IMPROVEMENT DISCUSSION

The ASIG cochairs opened the afternoon session with an opportunity to voice opinions on things that the ASIG needs improvement on. Suggestions from any perspective were welcome, but the intent was to identify ‘lessons learned’, and find ways to improve the processes of creating new attachments. The discussion revolved around two questions: (1) what needs improvement? (2) what has been working?

WHAT NEEDS IMPROVEMENT

  • Starting on time
  • Agenda preparation (including ability to determine which subject matter experts will be available when)
  • Subworkgroup cochairs not always able to attend the meetings
  • Monitoring financial requirements (conf calls, postage, etc).
  • Attachment specific workgroup co-chair continuity (& need for project management experience). Suggestion to provide ‘mentoring’.
  • Access to domain experts / commitment to participate
  • Need template for “newbies” (to include attachments background, HL7 background, HIPAA background).
  • Need for established agenda months in advance in order to get appropriate travel arrangements made (NOTE: state agencies need agenda on letterhead in order to get travel approval).
  • On site registration for next meeting (this was a recommendation to take to the Board for discussion).
  • All slide presentations should have speaker notes within the slides & also be posted to the website.
  • Tutorials should not require that all cochairs be involved, since that takes away from facilitation of ASIG workgroup meeting time. (For the most part, this has been corrected).
  • Tutorials should be given as early in the week as possible.
  • An “Intro to HL7 for attachments” tutorial should be created (as a combination of the Intro to HL7 & Attachments Tutorials). This is because the intro to HL7 tutorial is needed in order to understand the Attachments tutorial. Also, the current introduction tutorial seems to be geared toward hospitals.
  • Consideration should be given to possible ‘lunch time’ discussions, where table clusters can be formed as a “Q & A” group. Co-chairs could sit at different tables. Also a suggestion to have a buddy system established within the ASIG, or a “meet the expert” session.
  • Consideration should be given to only having one cochair in the workgroup session at a time so that other cochairs can be afforded the opportunity to broaden exposures by attending other sessions.

WHAT’S BEEN WORKING?