Information standards in healthcare Part 1

The healthcare world has a headspinning proportion of standards relevant to information management. Getting useful information on internet about such things is easier said than done. My thanks to all those who had some genuine information out there for the reentrants like me.

Title II, Administrative Simplification of the HIPAA of 1996 called for efficient and electronic transaction for administration and finance in healthcare. It impacted all "covered entities". American National Standards Institute (ANSI)standard was preferred by the federal regulators. Some of the key ANSI standards are Accredited Standards Committee(ASC) X12, National Council for Prescription Drug Program (NCPDP), Health Level Seven (HL7). An episode of health care may involve several HL7 messages and X12 transactions running sequentially or concurrently, all communicating about the the same health care “objects” or events. This may raise the issues of interoperability id data semantics to not match.

New version of current transactions and new transacation are being worked upon.The currently used formats being upgraded from X12 Version 4010A1 to 5010 and from NCPDP 5.1to D.0 (Refer to http://www.cms.hhs.gov/Versions5010andD0/downloads/5010_Provider_Natl_Conf_Call_06092009.pdf for more information). Jan 1, 2012 is the cutoff for all old transaction.
An over view of the interaction of X12 messages and HIPAA cross reference is given below:
HIPAA Transaction X12.
Claim 837
Eligibility 270/271
Auth. Request 278
Claim Status 276/277
Enrollment 834
Remittance 835
Premium Pmt. 820
Attachment 275
ACK TA1/997




Note: The UB04, CMS 1500 are standards to align the paper form to the electronic format.The CMS-1500 is the standard claim form used by a non-institutional provider or supplier to bill Medicare carriers and durable medical equipment regional carriers (DMERCs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.

In terms of the the contents of the electronic message, some other terms are relevant.
Diagnosis Related Group (DRG) is essentially categories under which reimbursements are sought for diseases classified under International Classification of Diseases (ICD-9). ICD-9 is used for inpatient and outpatient diagnosis and inpatient procedures (ICD-9-CM). Current Procedure Terminology (CPT) is used for outpatient services rendered.