Colorectal Cancer(CRC) Screenings Mandate-Part II

There is age limit for both of Cologuard and CT Colonography (Virtual Colonoscopy) screening test. None of these is applicable for patients whose age are below 50 or above 85. There is specific CPT  and diagnosis codes for both of them. This mandate of the USPSTF will come into force from  January1, 2017.  Let see their common features below:

Features of  Cologuard: 

Benefits: Contract benefits once every three years.

Members: Members- adults aged 50-75 or 76-85

Providers: IN Network & Out of Network

Provider Type: Laboratory

CPT code: 81528(Oncology Colorectal Screening)

Primary diagnosis codes:

Ø  Z00.00(Encounter for general adult medical examination without abnormal findings).

Ø  Z00.01(Encounter for general adult medical examination with abnormal findings)

Ø  Z12.11(Screening for malignant neoplasm)

Ø  Z12.12(Screening for malignant neoplasm of rectum)

Ø  Z83.71 ( Family History of Colonic Polyps)

Features of  CT Colonography(Virtual Colonoscopy) 

Benefits: Contract benefits once every five years.

Members: Members- adults aged 50-75 or 76-85

Providers: IN Network & Out of Network

Provider Type: Laboratory

CPT code: 74263(CT for Colonography Screening)

Primary diagnosis codes:

Ø  Z00.00(Encounter for general adult medical examination without abnormal findings).

Ø  Z00.01(Encounter for general adult medical examination with abnormal findings)

Ø  Z12.11(Screening for malignant neoplasm)

Ø  Z12.12(Screening for malignant neoplasm of rectum)

Ø  Z83.71 ( Family History of Colonic Polyps)

Colorectal Cancer(CRC) Screenings Mandate-Part I

Cancer is a fatal disease for mankind all over the world. Cancer is of various types, one of them is colorectal/colon cancer. Colorectal cancer is a cancer that starts in the colon or the rectum. These cancers can also be named colon cancer or rectal cancer, depending on where they start. Colon cancer and rectal cancer are often grouped together because they have many features in common. Colon cancer and rectal cancer make up colorectal cancer (CRC).

As per American Cancer Society, colorectal cancer is the third leading cause of cancer-related deaths in the United States when men and women are considered separately, and the second leading cause when both sexes are combined.

Earlier people's  thinking was that where there was cancer, there was no answer. But with the great advancement of medical science, there are many answers now . One of them is screening of cancer in earlier stage. Screening is the process of looking for cancer or pre-cancer in people who have no symptoms of the disease. There are different types of screening tests for colorectal cancer which help to detect colon or rectal cancer in earlier stage. Tests used to screen for colorectal cancer include:

Ø  Guaiac-based fecal occult blood test (gFOBT) and fecal immunochemical test (FIT)

Ø  Stool DNA test or Cologuard

Ø  Sigmoidoscopy

Ø  Colonoscopy

Ø  Double-contrast barium enema

Ø  Computed Tomographic Colonography(CTC) or Virtual Colonoscopy.

In order to comply with Affordable Care Act(ACA), health insurance companies will have to include Computed Tomographic Colonography(CTC) and Cologuard testing in their different health plans. The U.S. Preventive Services Task Force (USPSTF) has Grade A recommendation for Computed Tomographic Colonography(CTC) and Cologuard screening test. The USPSTF made this recommendation on June 15, 2016. Grade A recommendation of USPSTF means that the net benefit for health insurance policy holders is substantial.

CT Colonography or Virtual Colonoscopy:

CT Colonography is a method to examine the inside of the colon by taking a series of x-rays. A computer is used to make 2-dimensional (2-D) and 3-D pictures of the colon from these x-rays. The pictures can be saved, changed to give better viewing angles, and reviewed after the procedure, even years later. 

CT Colonography is noninvasive colorectal cancer screening used as an alternative to colonoscopy for individuals showing no signs or symptoms and no previous concerning medical history. It is noninvasive that means the testing does not require inserting an instrument through the skin or into a body opening.

Computed Tomographic (CT) Colonography is also called virtual colonoscopy (VC). Because it replaces conventional colonoscopy that requires passage of an endoscope through the rectum to the large bowels.

 Cologuard:

Cologuard is a colon cancer screening test based on the latest advances in stool DNA science. Cologuard tests for blood in the stool. Like CT Colonography, Cologuard is noninvasive colorectal cancer screening used as an alternative to colonoscopy for individuals showing no signs or symptoms and no previous concerning medical history. 

Facets Claims Processing application group

The beauty of facets is that it covers all aspects of claims processing. The Claims Processing application group consists of those applications that enables health care payer organizations  to record, process, track and run inquiries on dental, hospital and medical claims. This application group has more than 20 applications, some of which are as follows:

1) Claims Inquiry

2) Dental Claims Processing

3) Disability Claims Inquiry

4) Disability Claims Processing

5) Encounter Hospital Processing

6) Encounter Medical Processing

7) External Claims Editing

8) FSA Claims Processing

9) Hospital Claims Pre-Pricing

10) Hospital Claims Processing

11) Medical Claims Pre-Pricing

12) Medical Claims Processing

Facets Capitation/Risk Allocation application group

The Capitation/Risk Allocation application group consists of those applications that allows health care payer organizations to establish and maintain information that is necessary to direct payments and/or allocate funds to the appropriate service providers and/or process claims for members with capitated service agreements. This application group has more than 15 applications, some of which are as follows:

1) Average Member Premium

2) Capitation Inquiry

3) Capitation Schedule Definition

4) Claim/Encounter Mapping

5) Common Capitation Relationship

6) Cycle Description

7) Fund Definition

8) Lifestyle Rate Factor

9) Manual Capitation Adjustment

10) Member Retro Adjustment

Features of Electronic Data Interchange(EDI)

What is EDI?

EDI stands for Electronic Data Interchange. The transfer of structured data, by agreed message standards, from one computer system to another without human intervention or interference is called EDI or Electronic Data Interchange . Standard EDI X12 format data is text file separated by segment, element and sub-element delimiters (separators). Each segment is displayed on the separate line.

EDI is governed by standards released by ASC X12 (The Accredited Standards Committee). Each release contains set of message types like invoice, purchase order, healthcare claim, etc called Transaction. Each message type has specific number assigned to it instead of name. For example: an invoice is 810, purchase order is 850 and healthcare claim is 837.

What are the major HIPAA mandated Standard transaction formats?

A key component of HIPAA is the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans and employers. The major standard transaction formats that are mandated by HIPAA are the following: 

·         Health Care Claim Institutional (837I)

·         Health Care Claim Professional (837P)

·         Health Care Claim Dental (837D)

·         Health Care Claim Payment/Advice (835)

·         Health Care Eligibility Benefit Inquiry and Response (270/271)

·         Health Care Claim Status Request and Response (276/277)

·         Health Care Services Review Request for Review and Response (278)

·         Benefit Enrollment and Maintenance (834)

·         Payroll Deducted and Other Group Premium Payment for Insurance Products (820)

What is X12N?

X12 indicates EDI and the N identifies the Insurance Sub-Committee that is responsible for developing EDI standards for the insurance industry. There is a special healthcare task group within  this sub-committee responsible for the developing of health care insurance transactions. The  Insurance Sub-Committee is under the Accredited Standards Committee(ASC) which is commissioned by the American National Standards Institute(ANSI) to develop standards for Electronic Data Interchange(EDI).

What are the benefits of EDI?

i) Electronic transactions provide significant benefits compared with paper transactions:

EDI streamlines transaction processing formats are pre-edited to reduce common errors in claims data entry. This reduces the re-entry of the same data.

ii) It also reduces delays caused by scanning and re-keying.

iii) EDI also reduces operating costs and increases staff productivity.

iv) Improves cash forecasting & cash flow.

v) Faster submission of accurate  claims results in quicker payments and reduced receivables.

vi) Provides positive acknowledgement of transaction receipt

vii) Eliminates the  cost of handling and storing paper documents

What is HIPAA?

HIPAA stands for  the Health Insurance Portability and Accountability Act of 1996. It is  a federal law which was enacted on August 21, 1996. The Act contains the  following five sections, or titles:

Title I:  HIPAA Health Insurance Reform

Title II:  HIPAA Administrative Simplification

Title III:  HIPAA Tax Related Health Provisions

Title IV:  Application and Enforcement of Group Health Plan Requirements

Title V:  Revenue Offsets

HIPAA Title II directs the U.S. Department of Health and Human Services(HHS) to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. It also addresses the security and privacy of health data. Collectively these are known as the Administrative Simplification provisions.

The U.S. Department of Health and Human Services (DHHS) develops and publishes the rules pertaining to the implementation of HIPAA and standards to be used.

Major features of HIPAA:

§  Reduces administrative burden and cost for providers and payers

§  Creates a national standard for electronic transactions

§  Increases speed of financial transactions resulting in faster payment for services

§  Simplifies the exchange of information and reduces paperwork

§  Provides a more complete picture of healthcare and improves quality

§  Improves privacy and security of healthcare information.

Features of EDI 837P- Part II

Functional Group:

A Functional Group consists of one or more related Transaction Sets sharing the same Functional Group ID. Functional Group is like an envelope for Transaction Sets that starts with a GS (Functional Group Header) segment and ends with a GE (Functional Group Trailer) segment.

Sample GS:

GS*HC*99999999999*888888888888*20111219*1340*1377*X*005010X222A1~

Sample GS:

GE*1*1377~

GS06 (Group Control Number) and GE02(Group Control Number) must match

Transaction Set:

A Transaction Set  consists of  one or more data segments conveyed between trading partners. It usually represents a business document. Transaction Sets are defined in the X12 standard with a number and name, a statement of purpose, a Functional Group ID, and a table listing the included segments, their position numbers, requirement designation, maximum usage, and loop repeat counts. Transaction Sets start with an ST (Transaction Set Header) segment and end with an SE (Transaction Set Trailer) segment.

Sample ST:

ST*837*0001*005010X222A1~

Sample SE:

SE*39*0001~

ST02(Transaction set control number) and SE02(Transaction Set Control Number) must match.

Loops:

A loop is a set of mutually related segments in a Transaction Set. Segments are grouped together in this way so that it  conveniently represent a block of related information.