I didn't realize that was mandated by law? Surely not down to individual codes?
If that is what you are talking about, it kind of makes sense. Part of how the industry obfuscates is by using a lot of different terminology for the same thing, thus nobody can do price comparison across vendors. But of course, trying to impose order onto something purposefully confusing, is going to be difficult.
Something I wrote about the ICD10 coding system many years ago. These are real billing codes:
It is possible to arraigned the codes in rather amusing orders such as:
I required a Face Transplant, from a Cadaver; “0WY20Z0 Transplantation of Face, Allogeneic, Open Approach Transplantation of Face, Allogeneic, Open Approach” after my many spacecraft crashes into the ocean; “V9541XD Spacecraft crash injuring occupant, subsequent encounter”.
Sadly the first Face Transplant failed so one was grown in a lab for the second Face Transplant; “0WY20Z1 Transplantation of Face, Syngeneic, Open Approach Transplantation of Face, Syngeneic, Open Approach”.
Alas all of this made my “F52 Sexual dysfunction not due to a substance or known physiological condition” became so bad that I tried to harm myself with a jellyfish; “T63622A Toxic effect of contact with other jellyfish, intentional self-harm, initial encounter”. -- Amusement with the Medicare ICD10 Billing Codes –
ICD-10 is only one of several code systems (terminologies) used in HIPAA mandated transactions. The actual billable procedures for outpatient care are typically coded using CPT / HCPCS. The ICD codes are usually supplementary, to indicate a patient's condition as part of establishing medical necessity. The industry will move to the new ICD-11 version in a few years.
The HIPAA final rule mandates ASC X12 as the standard format for certain interactions such as eligibility and claims. It's old and somewhat clunky, but it's not terribly hard to implement. Libraries are available for most popular languages. Even if we replaced X12 with a modern format like HL7 FHIR (which is now legally allowed for some interactions such as prior authorization) that wouldn't solve the fundamental business, legal, and clinical problems.
It’s terrible to implement at the business and industry level - the required details enclosed with the messages are wholly insufficient to properly communicate claims as well as claim payments between payers and providers. Yet nothing can be done as the law requires its usage.
Could you clarify which specific details are missing from the messages? Additional clinical documentation can be sent in 275 attachments.
The law does not specifically require X12. The law gives CMS the authority to set technical standards and they chose X12 for those transactions because there was no other practical option. But recently they have granted at least one exception to use FHIR instead.
