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Colorado Takes the Initiative to Clean Up Claims

Standardizing claims statewide is good news for coders.

The Medical Clean Claims Transparency and Uniformity Act (House Bill 10-1332) was signed by Colorado’s Governor Bill Ritter May 12, 2010. The bill requires the executive director of the Colorado Department of Health Care Policy and Financing (HCPF) “to convene a task force of industry and government representatives to develop a standardized set of payment rules and claim edits to be used by payers and health care providers in Colorado.” The standard set will apply to all payers having contracts with providers in Colorado. The Colorado Medical Society was instrumental in passing this bill, also known “informally” as the Colorado Clean Claims Initiative.
The goal of the Colorado Clean Claims Initiative is to create one consistent set of edits everyone knows and uses to ensure a claim is coded, submitted, and processed cleanly the first time.

Why Colorado?

Task force member Wendi Healy, CPC, of Colorado’s Western Nephrology said, “Colorado is a very progressive state when it comes to health care reform. The Colorado Blue Ribbon Commission for Health Care Reform (locally known as the 208 Commission) was created by the Colorado legislature in 2006 to decrease health care costs for Colorado residents, and has many tiers to it; one of which is to reduce administrative costs in the health care system.”
The co-chairs of the task force are Marilyn Rissmiller of Colorado Medical Society and Barry Keene from Keene Research and Development. Healy told Coding Edge that Keene is a Colorado resident who has not been employed in the health care arena, “but is a well-educated consumer, who saw what a monster we have all created in the health care industry and was willing to step up to the plate to help change it.”
Vermont has also passed a law directing investigation of the value of such standardizations, and the AMA is supporting the Vermont Medical Society in its efforts,” according to American Medical Associations (AMA’s) Standardization of a Code-editing System White Paper (November 2011, page 6).

HCPF Creates a Task Force of Claims Experts

The task force is represented by 28 individuals from AMA, Colorado Medical Society, Colorado Hospital Association, Anthem/Wellpoint, UnitedHealthcare, Kaiser Permanente, Rocky Mountain Health Care (RMHC), Aetna, McKesson, OptumInsight , NHXS, Relative Value Studies, and ambulatory surgical centers (ASCs); and is made up of coders, billers, payers, vendors, and physicians chosen through an online application. Loaded with Certified Professional Coders (CPCs®), the task force includes these AAPC credentialed members:

  • Valerie Clark, CPC, represents payer-side, Kaiser
  • Rebecca Craig, CPC-H, Harmony Surgery Center, CASCA member
  • Kimberly Davis, CPC, physician billing at University Hospital
  • Wendi Healy, CPC, Western Nephrology, represents Colorado Medical Group Management Association (MGMA)
  • Amy Hodges, CPC, CPC-I, billing revenue cycle management, Bloodhound Technologies, Contracting w/States to implement NCCI for Medicaid
  • Ryshell Schrader, CPC, Community Reach Center, (MGMA)
  • Nancy M. Steinke, CPC, CPC-H, represents payer-side, RMHP
  • Beth Wright, CPC, Anthem, CCI committee chair

There are several other AAPC members on the team, as well. According to Healy, “The task force has grown since they originally started. Their goal when choosing the task force was to be sure they had good representation.”
An HCPF Hot Topics Legislative Report from Sept. 30, 2010 says the task force members must have these qualifications:

  • Expertise in the areas of coding, payment rules, and claim edits
  • Hands-on experience with the impact they have on payment of professional health insurance claims
  • Expertise including a technical understanding of the logic surrounding unbundling, mutually exclusive, multiple procedure reduction, global surgery days, place and type of service, assistant surgery, co-surgery, team surgery, total/professional/technical splits, bilateral procedures, anesthesia services, and the effect of CPT® and HCPCS Level II modifiers

Healy said, “It is the first time the industry has really put together this many players in the game and have everybody just sit down and say ‘even though we are speaking the same language, we aren’t.’ For example, when we first sat down we discovered what we call a claim edit, payers call a claim audit.” Healy continued, “We told them our side doesn’t like the word audit; let’s not use the word audit.”
The task force’s timeline for critical mileposts is:

  • Dec. 2, 2010 – Begin work and develop a base set of standardized payment rules and claim edits
  • Nov. 30, 2012 – Adopt base set
  • Dec. 31, 2013 – Adopt complete set (by filling in gaps)
  • Dec. 31, 2013 – Develop recommendations on implementation and maintenance
  • 2014+ – Implement

Task Force Creates Framework for Initiative

In the task force’s current effort to move towards a standard code editing system, they will identify a base set of rules and edits using these existing national industry sources:

  • National Correct Coding Initiative (NCCI) edits
  • The Centers for Medicare & Medicaid Services (CMS) directives, manuals, and transmittals
  • Medicare Physician Fee Schedule (MPFS)
  • CMS national Clinical Laboratory Fee Schedule
  • HCPCS Level II coding system and directives
  • CPT® coding guidelines and conventions
  • National Medical Specialty Society coding guidelines

Healy said, “We are not recreating the wheel. We are looking at industry standards that are already in place, CPT®, HCPCS, and basically unifying things.”

First Step of Many: NCCI Evaluation

The task force is developing an initiative to consider what would happen if it started with NCCI as a “skeleton” for the bundling process through an NCCI-sub-group team, which analyzes NCCI concepts and methodologies, to understand its application and to make recommendations to the HB 10-1332 Colorado Task Force. The analysis is based on relative value units (RVUs). They evaluate the NCCI edits where a denied code has the higher RVU.
“This has been really informational on how codes get the way they are, how we in turn use that information, how it’s interpreted on both sides of this, and choosing language that is acceptable to both sides,” Healy said. “We started with the NCCI edits. There is a company called NHXS. They work mostly on the physician-side and run all the claims up against the edits.” NHXS has “a list of all of the edits that all of the insurance companies are using.” They are able to show the task force the frequency with which specific CPT®, NCCI, or other types of edits occur.
NHXS has “been incredibly helpful with bringing data to the table that can show us where we may run into issues,” Healy said. “They run thousands and thousands and thousands of coding edits in their databases. They show us the data where there are times when NCCI turns the code upside down and pays the lower value.” NHXS uses this vast library to determine if a payer’s edit runs counter to generally accepted conventions. “They use this information to show us why we can and can’t do certain types of things,” Healy said. “The NCCI is only the first issue we are tackling. We will also be reviewing modifier usage, place of service code rules, assistant at surgery rules, and many other areas.”

What Does This Mean for Coders?

At one of the task force meetings someone from the payer-side suggested they make a recommendation to hire certified coders. Healy said, “Absolutely!” The task force realizes that one of the problems
they face is that, according to Healy, “some of the people on the job have not been trained on why we bill, the way we bill … there will be people who do not know how to play by the rules, but certified coders are trained to do this.”
Although the recommendation of using only certified coders came up in the discussion, Healy said it “doesn’t necessarily mean that we can make it part of the law, but it certainly has been brought up by both sides that certified coders know the information and would be more effective in using it.”
We all have thought, “wouldn’t it be great if we could all just use the same guidelines for coders.” Healy said the way things are now, “You have to know which insurance you are billing and if the patient changes insurance, you have to go back and redo the whole system on how you entered the code. It is such a disaster when it comes to those types of things.” Healy added, “And then if they change the rules on you and you have to go back in again and start all over from the beginning.” Standardizing all payer claims, she concluded, “is something that really should be helpful for coders, especially those who do surgical types of procedures.”

Will Other States Take the Initiative?

Healy is on the Task Force’s Sustainability Committee, trying to figure out how the industry can get the information it needs without additional cost to the system. “This type of effort would be very helpful to other coders in other states, as well,” Healy said. “Colorado is a great place to start since we have the processes already in place, but this is really a united effort that would help everyone in health care.”
Nationally people are watching what is going on with this initiative. The task force is in contact with Washington about the progress of this effort.
As far as AAPC’s stand on standardizing claim edits, on Nov. 17 and 18, the National Committee for Vital Health Statistics held hearings on the need for uniform standards and edits across the industry. AAPC’s Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC, vice president of ICD-10 education, offered testimony on the daily frustrations currently encountered by AAPC members. If you’d like to read her testimony about the need for a unified edit standard, go to AAPC News.

Michelle A. Dick is executive editor at AAPC.


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