Q How does HIPAA pertain to coding and billing?

A When you think of HIPAA, you probably think of privacy and security, not coding and billing. It's easy to forget that the government enacted HIPAA to streamline medical billing and payment processes. Currently in the United States, about 400 different coding-related formats, both paper and electronic, are used. HIPAA aims to standardize these formats and eliminate or greatly reduce paper forms by establishing eight electronic formats. Effective Oct. 16, you and your payors must do all of your reimbursement-related communications on these forms.

The bad news? The forms are complicated. The good news? Your payers can no longer say that they won't pay the claim because they don't "recognize" the codes you've sent them. Everyone must now use the same forms and codes.

Q Will CMS extend the Oct. 16 deadline?

A CMS cannot extend the Oct. 16 deadline for compliance with HIPAA regulations on electronic transactions and code sets, but will be lenient with enforcement for a short time after that date, officials say.

Q What are the 8 "forms?"

A They don't resemble traditional forms; they're a collection of data segments transmitted electronically. They may be downloaded and will be included in vendor software upgrades. When sending claims, your coder must fill out each field of the "form" with HIPAA-compliant codes for the claim to be valid. The government designates the eight transaction forms as follows:

• ASC X12N 834 - Benefit Enrollment and Maintenance, Version 4010;
• The ASC X12N 270/271 - Health Care Eligibility Benefit Inquiry and Response, Version 4010;
• The ASC X12N 278 - Health Care Services Review-Request for Review and Response, Version 4010;
• The ASC X12N 837 - Health Care Claim: Institutional, Volumes 1and 2, Version 4010;
• The ASC X12N 837- Health Care Claim: Professional, Volumes 1 and 2, Version 4010;
• The ASC X12N 837 - Health Care Claim: Dental, Version 4010;
• The ASC X12N-276/277 - Health Care Claim Status Request and Response, Version 4010; and
• The ASC X12N 835 - Health Care Claim Payment/Advice, Version 4010.

Q So when would you use these forms?

A Let's look first at the 837 forms, because these are the ones that you'll use to submit the reimbursement claim to the payer. An ASC or hospital would submit the "institutional" form. A physician in an office-based surgical setting would use the "professional" form. The "dental" form is strictly for specialists in the field; in other words, a hospital outpatient department that performs occasional dental surgery would use the 837 "institutional" form, not the "dental" one.

The 276/277 forms are used for communications about the status of an 837 form. Facilities fill out the inquiry with the 276 and the insurer replies with the 277.

The 835 form is the final payment transaction. This form verifies that the check has been cut to the facility.

The other forms are all related to record keeping and pre-procedure inquiries. The 278 form is used to ask the payer if prior approval is necessary to perform a certain procedure on the patient. The 270/271 forms are used for inquiries about the current eligibility status of a patient; facilities send the 270 form to ask if a patient is a current enrollee with the payer and the payer replies with the 271. The 834 form is used for record keeping about the benefit enrollment of patients.

Q What does HIPAA require of your payers?

A They need to recognize and use the same forms and code sets that you use. Ultimately, that should simplify your billing, because you won't have to use different forms for different payors. Even if the form and codes are HIPAA-compliant, the health plan may still deny reimbursement of the procedure for other reasons. HIPAA requires health plans to keep code sets for the current billing period and denied claims appeals periods (specified by the terms of the health plan's contract with your facility).

Q How do you fill out these electronic forms?

A The coding data fields on each form must be filled out with a specific code set recognized under HIPAA. Most of these code sets should be familiar to your coders, such as CPTs and ICD-9 codes.