Will you hold, please? DHHS action overdue
Will you hold, please? DHHS action overdue
Infusion industry awaits coding decision
"In essence, what we are trying to do is achieve recognition and reimbursement for all professional services that are provided with infusion therapy," says David M. Franklin, director of reimbursement for Continuing Care Services at Bon Secours Health Services in Grosse Point, MI, and a member of the Home Infusion Electronic Data Interchange Coalition (HIEC). "We are going about this in a number of ways, perhaps most significantly through our efforts toward national standardization of coding procedures."
Franklin says HIEC was created by home infusion providers across the United States to address industry concerns related to the lack of standardized coding mechanisms for home infusion services and the need to increase electronic data interchange (EDI) and electronic claiming capabilities in the infusion industry. The HIEC Coordinating Committee says its objectives are intrinsically linked to the objectives of the National Home Infusion Association (NHIA), and that the industry at large would be best served by combining the activities of the two organizations. Franklin says HIEC’s objectives include:
• decreasing days of sales outstanding throughout the infusion industry nationwide;
• supporting and standardizing EDI transmission of infusion-related data on a national basis;
• standardizing infusion coding methodologies nationwide;
• decreasing the cost of processing and adjudicating home infusion claims;
• increasing the efficiencies in infusion billing and reimbursement processes;
• facilitating documentation of and the billing and reimbursement for professional and cognitive services provided by infusion industry professionals.
HIEC’s proposal made to and accepted by NHIA points out that "lack of standardized coding mechanisms and EDI capabilities have plagued the infusion industry since its inception. Administrative inefficiencies and bureaucratic-related expenses have caused infusion providers to direct inappropriate amounts of resources towards the funding of accounts receivable and excessive overhead costs."
Know your code
Franklin says the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires coding accepted on a federal level for all health care services. HIPAA presented a unique opportunity for the home infusion industry to obtain a devoted coding system. Language contained within this legislation states the intent to improve "the efficiency and effectiveness of the health care system, by encouraging the development of a health information system through the establishment of standards and requirements for the electronic transmission of certain health information."
The Department of Health and Human Services (DHHS), responsible for implementing this section of the legislation, failed to publish the final choice of allowable codes in November 1999 as agreed. DHHS is required to select from existing standards unless they do not meet the needs of affected parties. Health care payers will be required to accept the standards adopted by DHHS. The opportunities for the infusion industry are clear. If the industry is able to convince the DHHS that none of the existing standards meet the needs of the industry, it is possible that the HIEC codes, which are solely devoted to the purpose of describing home infusion products and services, could be adopted as a national standard and infusion professionals could finally begin receiving reasonable reimbursement for their services.
Supervision required
According to Franklin, none of the existing codes appear adequate for infusion services. "There are other codes out there standardized on a national basis. They all have different functions, but none of them are for infusion." As Franklin points out, the American Medical Association’s current procedural terminology codes require the direct supervision of a physician, something not generally found in home infusion services. Health Care Financing Administration’s Common Procedure Coding Systems codes are strictly product-driven and don’t describe infusion services. International Classification of Diseases Volume 9 codes describe disease and injury states and certain surgical procedures. No section of this system describes home infusion services. National Drug Codes describe medications only.
The per-diem structures that have become the standard reimbursement methodology in the infusion industry would not be allowed under the HIPAA legislation, and the administrative simplification that is the intent of the HIPAA legislation would not be possible for the home infusion field. Franklin says that the most troublesome and disturbing possibility is that the drug element of infusion therapy would be split out, treated as a retail drug transaction, and reimbursed at cost plus a nominal dispensing fee. This reimbursement methodology would fail to acknowledge and compensate professionals for reviewing lab work, recommending medication changes due to clinical findings, compounding medications, monitoring potential drug interactions, and coordinating therapy with other health care professionals.
No standard set
Franklin’s HIEC group developed a coding system specific to infusion therapy and last spring asked the government to include it in its national standards. "We’re not expecting them to do so," he says. "But they haven’t published their final standards yet, so we can’t say for sure they’re not going to. Keep in mind that these codes we’ve designed are still under review. All infusion providers have not accepted them as a national standard. If they were, there are still some changes that would need to be made before we could start using them."
HIEC’s proposal notes that "the current HIEC system has been designed for the private sector mirrors the per diem methodologies most common in private sector infusion reimbursement and is not designed or intended for use with the Medicare system, which has limited infusion benefits and its own coding structure." The HIEC (draft) for an infusion coding system, has been well-received by the infusion industry, with provider support growing rapidly within a short period of time. (See HIEC coding system, inserted in this issue.) "It is perhaps the single most widely recognized system that is specific to infusion products and services," says Franklin, "and is accepted by more than 80 payers across the country."
Need More Information?
David M. Franklin, 22100 Greater Mack Ave., St. Clair Shores, MI 48080. Telephone: (810) 498-4950.
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