Objectives

1. Briefing: CHCS Provider Specialty Codes, HIPAA Provider Taxonomy & National Provider Identifiers (NPIs) Date: 20 March 2007 Time: 1510 - 1600

2. Objectives • Describe the Composite Health Care System (CHCS) Provider Specialty Code and its use in the Military Health System (MHS) and the importance of its accuracy • Describe the Health Insurance Portability & Accountability Act (HIPAA) Provider Taxonomy Code and its use in MHS Billing • Describe the National Provider Identifier (NPI) and its use in MHS Billing

3. Nomenclature • CHCS Provider Specialty Code – Military unique codes used to identify a provider’s specialty. They existed prior to the HIPAA Provider Taxonomy • HIPAA Provider Taxonomy – Relatively new federal codes used to tell a provider’s specialty • Two different types, individual and agency • National Provider Identifier (NPI) – Ten digit code that uniquely identifies a health care provider. Both individuals and organizations can obtain an NPI • Currently, no check logic in CHCS that takes the HIPAA Provider Taxonomy used when a provider submits for an NPI and compares it to see if it is the same specialty recorded within CHCS

4. Provider Specialty Codes (PSC) • Set of codes unique to CHCS • Current business rules preclude TPOCS from receiving CHCS Ambulatory Data Module (ADM) encounters with blank PSCs or PSCs > 900 • Exception of 901 – Physician Assistant • There is a difference between a Provider and a Clinic • Erroneous PSC means no bills generated • 702 (Clinical Psychologist) versus 954 (Psychology) • Site visit to large medical center found 20% of PSC fields were blank • Billable ADM encounter never reaches TPOCS • Lost revenue for the MTF

5. Correcting the CHCS PSCs • Get your site’s most current CHCS Provider Profile and review the PSC fields for accuracy • No blank fields • Billable providers have PSC under 900 (plus 901 – Physician Assistant) • Determine who’s responsible for maintaining the PSC fields at your MTF and TRAIN THEM!!! • Periodically review the CHCS Provider Profile to make sure the problem really has been permanently fixed

6. Just What Is a Taxonomy? • A combination of two Greek words • (taxis meaning arrangement or division and nomos meaning law • Defined as the science of classification according to a pre-determined system, with the resulting catalog used to provide a conceptual framework for discussion, analysis, or information retrieval • It takes into account the importance of separating elements of a group (taxon) into subgroups (taxa) that are mutually exclusive, unambiguous, and taken together, include all possibilities • It should be simple and easy to remember and to use

7. Who Maintains the HIPAA Taxonomy? • National Uniform Claim Committee (NUCC) has been responsible for the HIPAA Provider Taxonomy since 2001 • NUCC also responsible for maintaining the CMS 1500 paper claim form • Updates are published (released) twice a year in July and January • July publication is effective for use on 1 October and January publication is effective for use on 1 April • Current online listing is version 7.0, published 1 January 2007, and contains new codes that become effective 1 April 2007 • Requests for new taxonomy codes or modifications to existing codes should be sent to taxonomy@wpc-edi.com

8. 3 Levels to the HIPAA Provider Taxonomy • Three levels to the HIPAA Provider Taxonomy • Level I, Provider Type • Level II, Classification • Level III, Area of Specialization • Gets more specific as you go down each level

9. Taxonomy Level I • Level I, Provider TypeA major grouping of service(s) or occupation(s) of health care providers. For example: Allopathic & Osteopathic Physicians, Dental Providers, Hospitals

10. Taxonomy Level II • Level II, ClassificationA more specific service or occupation related to the Provider Type. For example, the classification for Allopathic & Osteopathic Physicians is based on the General Specialty Certificates as issued by the appropriate national boards. The following boards will, however, have their general certificates appear as Level III areas of specialization strictly due to display limitations of the code set: Medical Genetics, Preventive Medicine, Psychiatry & Neurology, Radiology, Surgery, Otolaryngology, Pathology

11. Taxonomy Level III • Level III, Area of SpecializationA more specialized area of the classification in which a provider chooses to practice or make services available • For example, the Area of Specialization for provider type Allopathic & Osteopathic Physicians is based on the subspecialty Certificates as issued by the appropriate national boards

12. Dentist Example • A general dentist is an "Individual" and clicking on the term "Individual or Groups (of Individuals)" expands the node as in the illustration below:

13. Dentist Example (con’t) • The Health Care Provider Taxonomy code set list is an ordered system of groups and categories indicating relationships. A general dentist is found by clicking the term "Dental Providers" and doing so displays:

14. Dentist Example (con’t) • Notice that "Dentist" has additional specialties below it and clicking the term displays those additional specialties as in the illustration below:

15. Dentist Example (con’t) • This is the lowest level in the list known as "Level III Area of Specialization" and "General Practice" is listed as code "1223G0001X." To verify that this code is what you will select, click the [more] link to display a definition:

16. Proposing Taxonomy Definitions • Not every code will display a definition. If you wish to propose a definition, do so in writing by sending an e-mail to: taxonomy@wpc-edi.com indicating which code you are defining along with the proposed definition

17. Adding New Codes or Making Modifications • The Health Care Provider Taxonomy code set levels are organized to allow for drilling down to the provider's most specific level of specialization. The ten-digit codes for each provider category are unique and contain no embedded logic. The codes and categories are to be used exactly as they are assigned in the taxonomy list • At no time should codes be separated to form new codes • If the taxonomy code set does not work for you, then submit a request • Requests for new taxonomy codes or modifications to existing codes should be sent to taxonomy@wpc-edi.com

18. Standard Notice of Proposed Rule Making (NPRM) Final Rule Publication Compliance Required Transactions & Codes Sets 05/07/1998 08/17/2000 10/16/2003 - with extension National Provider Identifier 05/07/1998 01/23/2004 05/23/2007 (2008<$5M) National Employer Identifier 06/16/1998 05/31/2002 07/30/2004 (2005<$5M) Security 08/12/1998 02/20/2003 04/20/2005 (2006<$5M) Privacy 11/03/1999 12/28/2000 04/14/2003 (2004<$5M) Timetable for Adoption of HIPAA Standards

19. National Provider Identifier (NPI) • National Provider Identifier (NPI) • Health care providers began applying for NPIs beginning 23 May 2005 • Health care providers, health plans, and health care clearinghouses must begin using the NPI in standard transactions NLT 23 May 2007 • Small health plans have until NLT 23 May 2008 • A 10-position numeric identifier (last digit is a check figure) • An Intelligence-free number • NPI Type 1 – for health care providers who are individual human beings • NPI Type 2 – for health care organizations

20. Use of the NPI Type 1 in the MHS • HA Policy 05-002 issued 26 January 2005 regarding NPI Type 1 • Requires “all Health Care Providers who furnish billable health care services or who may initiate and/or receive referrals must obtain an NPI Type 1.” • Services are responsible for ensuring all privileged/credentialed providers (including Reserve Component) obtain and submit their NPI to the TMA designated data base/repository prior to 23 May 2007 • Services SGs have issued Memoranda of Instruction detailing Service-specific instructions • As of 27 February 2007, 19,711 NPI Type 1 identifiers have been entered into DMHRSi • Still need an estimated 8,711 more NPI Type 1 identifiers! • Only 64 days remaining until 23 May 2007 deadline

21. Use of the NPI Type 2 in the MHS • HA Policy 05-012 issued 1 August 2005 regarding NPI Type 2 • Requires all organizational health care providers within the MHS to obtain an NPI Type 2. These include: • MTFs that bill third party insurers • Pharmacy dispensing sites • The Services are responsible for ensuring all applicable organizational health care providers obtain NPI Type 2 identifiers prior to 23 May 2007 • As of 27 February 2007 • 128 NPI Type 2 identifiers for MTFs have been entered into DMHRSi • 600 NPI Type 2 identifiers for pharmacy dispensing sites have been entered into DMHRSi • Only 64 days remaining until 23 May 2007deadline

22. New Paper Bill Forms • Use of new revised CMS 1500 Form required beginning 1 February 2007 • Form maintained by the National Uniform Claim Committee (NUCC) • Use of New UB-04 Form required beginning 23 May 2007 • Form maintained by National Uniform Billing Committee (NUBC) • Both new forms mandate use of NPIs beginning 23 May 2007

23. MHS SCRs to Support New Paper Bill Forms • MHS System Change Requests (SCRs) have been submitted for making changes to TPOCS (UB-04 & CMS 1500) and the CHCS MSA module (UB-04 only) to support the new paper claim formats • CHCS software change package to support the UB-04 will be available for MTFs to load beginning in early May 2007 • TPOCS software change package to support both the CMS 1500 and UB-04 being tested and readied for deployment • Billers will be able to edit the NPI field if the value is missing • MTFs need to start ordering the new UB-04 and CMS 1500 forms

24. HIPAA Resources on the Internet • TMA HIPAA Web site • http://www.tricare.mil/hipaa/ • National Uniform Claim Committee (NUCC) – CMS 1500 • http://www.nucc.org • National Uniform Billing Committee (NUBC) – UB-04 • http://www.nubc.org/new.html • HIPAA Provider Taxonomy Information • http://www.wpc-edi.com/taxonomy/more_information • HA Policy 05-002 - NPI Entity – Type 1 • http://www.ha.osd.mil/policies/2005/default.cfm • HA Policy 05-012 – NPI Entity – Type 2 • http://www.ha.osd.mil/policies/2005/default.cfm

25. Summary • The Composite Health Care System (CHCS) Provider Specialty Code and its use in the Military Health System (MHS) and the importance of its accuracy • The Health Insurance Portability & Accountability Act (HIPAA) Provider Taxonomy Code and its use in MHS Billing • The National Provider Identifier (NPI) and its use in MHS Billing

26. Quiz • If a Provider has a CHCS Provider Specialty Code of 954, is it a billable encounter? • The HIPAA Provider Taxonomy has how many levels? • An NPI Type 1 is used by what kind of provider? • What is the deadline for using NPIs in billing third party payers?