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Encounter Data System Gap Analysis Guidelines

Word of Encouragement

This is the most critical step in the process. When first presented with the task of comparing your data needs with those in the 837 claim / encounter standard it seems like a very daunting task. This task is tedious, but it does not have to be daunting. The purpose of this document is to help organize the resources necessary to accomplish the critical step of gap analysis on the 837 claim / encounter standard. You need to know whether or not what you need is supported by the standard or not. Without that knowledge system development efforts cannot successfully move forward.

Let's Begin

The UB-04 and its predecessors the UB-82 & UB-92 have long been the de facto standard for defining the core data content for billing and reporting of institutional health services. Based on that premise, a logical first step is to analyze the UB content for reporting health services in an institutional setting.

Step1A: Compare Your Institutional data requirements to the UB-04 data specifications as well as standard and proprietary electronic transmission formats.

  • Review the UB-04 Specification document. All of the UB-04 data elements are supported on the 837 claim / encounter standard. The UB-04 Specifications are available on the National Uniform Billing Committee (NUBC) web site - www.nubc.org. Note: you must be a subscriber to obtain the data specifications. Instructions for becoming a subscriber are available on the Web site. There is a nominal cost to become a subscriber. Note: All your data requirements supported in proprietary formats may NOT be supported in the UB-04 or the ANSI X12 837 Claim format standard.
  • Review your current transmission format to compare the data elements you currently collect with the data elements supported in the most current version of the Health Care Service Data Reporting Guide, which is currently the 5010 version. It should be noted that many state legacy systems utilize the Medicare Version 5 or 6 flat files. Since HIPAA mandated the use of the ANSI X12N 837 format, Medicare no longer maintains that flat file format. Any states still using that flat file format now would be using their own proprietary version of that format, since Medicare no longer maintains a standard version of that flat file format.
  • Review mappings to the 837 Institutional claim / encounter standard from any proprietary formats. These mappings will identify the gaps in the data content between the standard and the legacy system. Remember the wheel was invented before you were born. The purpose of these mappings would be to compare each data element collected on the system to be migrated to the national 837 standard format. This would include identifying differences in data definitions, identifying data elements that are currently collected on the legacy system that don't exist in the standard, as well as identifying data elements in the standard that are not currently collected on the legacy system. Before doing your own mapping it is recommended that you contact the National Association of Health Data Organizations (NAHDO) to find out if what you need has been done already. The web site for NAHDO is www.nahdo.org.
  • Review a variety of crosswalks to and from the 837 Institutional claim / encounter standard. The crosswalks will identify the relationships between the data elements national 837 standard format and the data elements in the format used to collect the data elements in the legacy system. Before creating a new crosswalk it is recommended that you contact the National Association of Health Data Organizations (NAHDO) to find out if what you need has been done already. The web site for NAHDO is www.nahdo.org.
  • Note: The purpose of the mappings is to identify gaps in the data content between the national standard and the legacy system to be migrated. The purpose of the crosswalks is to identify the relationships between the data elements in the national standard format and the format used to collect the legacy system data.

The HCFA 1500 has been the de facto standard for defining the core data content for billing and reporting of professional health services. Based on that premise, a logical first step is to analyze the HCFA 1500 content for reporting health services in a professional setting. The HCFA 1500 is maintained by the National Uniform Claim Committee (www.nucc.org).

It should be noted that there is currently no state collecting professional services data directly from the provider. There are some states that have started to collect professional services data from the payers. These All Payer Claims Databases (APCD) are in the early stages of defining the appropriate standards to help make the collection of data uniform across the country.

Step1B: The steps to identify the gaps in the available standards to report professional services would be similar to what is described above for institutional services is Step 1A with one notable exception, you may have to invent the wheel. Again a good resource to start this effort would be National Association of Health Data Organizations (NAHDO) at www.nahdo.org, some of whose members have been leaders in this initiative.

Step 2: Identify your data needs that are NOT supported in the ANSI ASC X12 standards. (See note about implementation guides in the ANSI ASC X12 Glossary)

  • Review the 837 standard, which may be purchased in hard copy from Washington Publishing Company (www.wpc-edi.com) or downloaded from the following URL (www.X12.org), Note: The workbook is only available to organizations or individuals that are ANSI ASC X12 members. The purpose of this review is to identify those necessary elements that are either:
    • Supported in the 837 standard, but not in the UB or HCFA data specifications.
    • Potentially supportable through changes to external codes lists; such as the UB value, revenue, condition, or occurrence codes.
    • Potentially supportable through changes to the ANSI ASC X12 standard.
  • The National Association of Health Data Organizations (NAHDO) is currently maintaining a survey of what various state discharge systems collect. (www.nahdo.org)