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Comments on HCFA-0149-P:
Standards for Electronic Transactions

Contents

Introduction

Comments provided to the AAFP on Standards for Electronic Transactions and Code Sets. Original 6/19/98. Revised: 01 Feb 2002.

Topics and Comments

I. Provisions

Timetable for implementations/penalties

• The time periods are too short, and the penalties too severe. See IX. Impact Analysis below. The rules should differentiate between integrated health care delivery systems and small practices.

III. Code sets

Comments on code sets

• ICD-9 CM: This is an abysmal code set. It is better suited to epidemiology studies in equatorial Africa than to documenting clinical care in America. It is not clear that ICD-10 is a significant improvement. We will have to support ICD-9, but it must be considered a lowest common denominator solution and better systems should be encouraged. ICD-9 CM should not be the only code set mandated for coding diagnoses and findings; HCFA should provide mappings to and from superior code sets to ICD-9.
• SNOMED: A promising code set that requires substantial work to be made practically useful.
• CPT: Needs to be moved into the public domain. We cannot have a required code set that belongs to a private organization. Otherwise we should replace it. The labels associated with codes are unusable in clinical settings.

HCPCS Level III

• They should indeed be eliminated. We must be fearful of the bureaucratic process that may be instituted for adding codes.

Transaction Standards

• New technologies for encoding transaction standards are emerging on the public Internet. In particular, XML (extended markup language) is a promising solution. Decisions on transaction standards should be reviewed in 2-3 years, with allowance for a transition to XML based solutions at that time.

VIII. New and revised standards

• Permitting new standards to be implemented is critical. Evaluation periods should be less for standards that are widely used in other industries, more for health-care specific standards. There should be objective performance standards for managing waiver requests (ie. no more than 5 person-hours to complete applications, turnaround on responses within 4 weeks).
• Look at the standards setting process implemented by the Internet Engineering Task Force and the WWW Consortium (W3C). Both have done well with testing and implementing new standards.

IX. Impact Analysis

• Expenses associated with transition should be treated as fully deductible business expenses. Impact should be diminished by providing incentives for implementation (decreased turnaround time, decreased processing fees) rather than penalties for non-implementation. There should be a period of several years when the new standards are encouraged through incentives, but not mandated. The impact may otherwise put many small rural practices out of business. The process will promote practice consolidation and, in the short term, increase practice overhead. In the longer term, if done well, standards will decrease overhead.