Just in time for Halloween, it's gotten dark, it's gotten cold, and now....we have HIPAA and its Transaction Code Sets coming back to haunt us!  Talk about spooky!  Luckily, we also have Ray Posa back to shed some light on TCS.

A thoughtful relative has shared some Helpful Halloween Hints.  Keep these in mind:
* When it appears that you have killed the monster, NEVER check to see if it's really dead.
* Do not search the basement, especially if the power has gone out.
* Don't fool with recombinant DNA technology unless you're sure you know what you're doing.
* If you're running from the monster, expect to trip or fall down at east twice, more if you are female. Also note that, despite the fact that you are running and the monster is merely shambling along, it's still moving fast enough to catch up with you.

On to the business at hand.....

~  Gayle

From:  Lynn Homisak
re:      Congratulations

Time to stop and recognize the good in this world!  CONGRATULATIONS to Anna Ornstein, wife of Dr. Hal Ornstein and mother of Zach and Tyler...on her being honored by the Howell, NJ, Chamber of Commerce on Friday, October 24th as "Volunteer of the Year" for her ongoing work with "Miles of Smiles."  Miles of Smiles is a birthday club for underprivileged children and seniors, founded by our own Dr. Ornstein.  We congratulate his beautiful wife (who is just as beautiful on the inside as the out) for contributing her time, effort and love into this very worthwhile project!  What a team, those Ornsteins!

Lynn Homisak
LynnPRT@msn.com
Renton, WA

*_*    *_*    *_*

From:  Eric A. Arp, DPM
re:      Clioquinal Cream  (Volume 52)

Found the cream you were looking for.  Company name is Moore Medical 800-234-1464, item number is 69198 for 30 gm tube at $4.45.

*_*  Stay away from certain geographical locations, some of which are listed here: Amityville, Elm Street, Transylvania, Nilbog (you're in trouble if you recognize this one), anywhere in Texas where chain saws are sold, the Bermuda Triangle, or any small town in Maine.  *_*

I recently read a story about one of the Blue Shields regarding HIPAA-compliant electronic claims. They said that if submissions have more than a few problematic claims they are rejecting the entire submission(prior to HIPAA they would accept most claims and reject only the problem claims). In addition, they are only advising the sender of 3 rejections at a time. Therefore, they end up fixing the first 3, resending the file and then getting 3 more! On top of that, the providers have to wait for the rejection report that they used to get immediately

What they are experiencing is the TCS Train Wreck.

By law, payors do not have to accept non-compliant claims after October 16, 2003. This is the date when TCS (transaction code sets) went into effect.

I was a recent participant at the National HIPAA Summit in Baltimore and one of the topics that my partner, David Fienberg (one of the developers of the X12 code sets), spoke about was the train wreck that could occur if all payors stopped payments on non-compliant transactions. It would bring the medical industry to a grinding halt.  Realizing this, and the fact that Medicare itself is not fully compliant, the government implemented the TCS contingency plan, which basically says that they will continue to accept legacy claims, i.e. Paper and non-HIPAA-compliant electronic claims, and allow providers more time to test their electronic claims. Most payors have followed the government’s lead on this, although they are not required to.

It is imperative that all providers begin testing their TCS and fully document their efforts. By law a payor can refuse to pay claims and providers could be fined for having non-compliant claims. What each provider must do is have a fully documented Plan (Yes, the one from October 2002, when everyone applied for their extensions) and document their continuing efforts to achieve compliance.

As for this Blue Shield, if they are going to withhold payment because a claim was non-compliant, I would suggest throwing it right back at them. It sounds like they are not compliant, either, and a case like this would be one for the state insurance commissioner. You see, if they say that claims are being rejected because they are non-compliant, then their response should be in the HIPAA-compliant format.

Briefly, here is how HIPAA transactions code sets are supposed to work. Your claim gets formatted in the new X12 format, the new universal format for claims.  It is then sent electronically to the payor.  Upon receipt the payor will generate a response code set saying “we received your claim”; they can no longer claim that your claim got lost or they never received it. Once received they process the claim and if there are exceptions they will, within 24 hours, generate another code set that gets sent back to you detailing ALL the exceptions, not just three at a time. Under the HIPAA TCS you should always know in 24 hours what the status is of any claim.

Unfortunately, the payors are depending upon the HIPAA confusion to hold up payments because once fully implemented, their payout cycle will go from weeks to days, and that will cost them huge amounts of money. Once we understand the motivations of the payors it all becomes very clear. The payors are being so gracious by allowing providers to continue to use legacy submissions because they get to hold on to the money much longer than they could under HIPAA.

That’s TCS in a nut-shell.

So a word to the wise, if you are not testing and or documenting real efforts to become compliant, in early 2004 you risk having your payments cut off.


By: Raymond F. Posa, MBA
Technology Advisor to the American Academy of Podiatric Practice Management
President, R. Francis Associates

Any questions or comments can be addressed to Mr. Posa by E-mail: Rposa@Rfrancis.com
Or visit WWW.NJHIPAA.COM

You can review previous installments from Mr. Posa at
http://www.footzine.com/FZ_H.htm

The Question:

Do the rules say we have to have monthly meetings about HIPAA the way we're supposed to for OSHA?  Or just that we all be trained?

The Answer:

As for monthly meetings, HIPAA does not specify any frequency of meetings and/or training.  It only requires that all staff members be formally trained and the training sessions documented and recorded and kept on file.


By: Raymond F. Posa, MBA
Technology Advisor to the American Academy of Podiatric Practice Management
President, R. Francis Associates

Any questions or comments can be addressed to Mr. Posa by E-mail: Rposa@Rfrancis.com

These questions and their answers will be archived on the FootZine web site on the "HIPAA FAQ" page, at http://www.footzine.com/FZ_50.htm
Email your HIPAA questions to: gaylejohnson@footzine.com


*_*  Beware of strangers bearing tools. For example: chain saws, staple guns, hedge trimmers, electric carving knives, combines, lawn mowers, butane torches, soldering irons, band saws, or any devices made from deceased companions.  *_*

The Questions:

Hi Gayle,

Can anyone tell me what injection code they use for injection of sinus tarsai?   We keep getting stumped.   And what is everyone using when they inject cortisone into a neuroma?

Thanks,

Gail Bennett
Spokane, WA

The Answers:

Injection into the sinus tarsi could be coded either as 20550 (injection tendon/ligament) or as 20605 (injection intermediate joint).  Remember to use an appropriate diagnosis with the procedure.  For the 20550 you would need a soft tissue diagnosis (example bursitis 726.79), for the 20605 you would need an joint diagnosis (example arthralgia 719.47).

The injection of a neuroma has been a hot topic of debate over the last year but the APMA Coding Committee and the consensus of the Codingline.com expert panel agree that the appropriate code would be 64450.  Remember to bill for the actual steroid used in the injection by using the J supply codes.

Crystal-Clear Coding tips by Dr. Ward are posted on the FootZine web site on this page:
http://www.footzine.com/FZ_C.htm

Here is link to an historic drawing that we can all relate to.
http://www.nlm.nih.gov/exhibition/dreamanatomy/da_g_III-A-12.html

It is part of an exhibit called "Dream Anatomy" at the National Institutes of Health (History of Medicine Division/National Library of Medicine).  The drawings in the Dream Anatomy Gallery date back as far as the 1500s and cover a wide range of human anatomy, including lower extremity images.  The one at the link above will surely seem familiar to us all.

*_*  Do not go looking for witches in the Georgia backwoods!  *_*

Have an enjoyable Halloween, and may your trick-or-treating include some chocolate!

 ~ Gayle