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Comments on HCFA-0149-P:
Standards for Electronic Transactions
Comments provided to the AAFP on Standards
for Electronic Transactions and Code Sets. Original 6/19/98.
Revised: 01 Feb 2002.
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
- 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
- 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.
Author: John G. Faughnan.
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