FREQUENTLY ASKED QUESTIONS

Reporting Physician Identifiers UPIN vs NPI
VHI will be switching from collecting the UPIN (Uniform Physician Identification Number) to the NPI (National Provider Identifier) for attending and operating physicians.   CMS is requiring the use of the NPI as of May 23, 2007, with small health plans allowed a delay until May 23, 2008. 

Significant delays in obtaining an NPI for physicians have been reported to VHI. To help address this, VHI began accepting either a UPIN or an NPI effective with discharges on and after January 1, 2007. VHI will continue this policy for discharges occurring through March 31, 2008.

Inpatient discharges and outpatient procedures occurring on and after April 1, 2008, must have a valid NPI when reported to VHI. UPINs will not be valid after that date. In addition, there will be no "unknown" values accepted.

Delaying full implementation to April 1, 2008, should allow those submitting data to VHI adequate time needed to obtain and to validate NPIs.

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Who is Affected by the New Law?
Ambulatory surgical centers (ASCs), hospital outpatient departments (HOPDs), and physician offices are required to report certain outpatient procedures.
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What Information must be Submitted? How is it to be Submitted?
Data comes primarily from a subset of the information routinely reported on the HCFA 1500 or UB-92-whichever the reporting entity routinely employ. Data may be submitted using an electronic record described in this document. As an alternative, if a reporting entity performs fewer than 100 or more of the selected procedures annually, paper copies of claims (HCFA 1500 or UB-92 or successors) may be provided with patient names and street address removed. This latter method may be used until January 2004 when all submission of data must be submitted electronically. See details within.

Hospitals and other providers participating in professional association private data sharing programs may have the data-sharing program submit ambulatory surgery data on their behalf. Please see Attachment #1, Outpatient Data Notification Form, to list the name of any organization submitting data on your behalf.

Those entities reporting outpatient procedures should check with their vendor about changes necessary to their electronic billing systems to capture and report the required information. Those using paper systems should review their forms for the ability to capture the necessary information.
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What Procedures must be Reported?
The procedures listed below have been approved by the Virginia Board of Health for reporting when performed on an outpatient basis:
  1. Colonoscopy
  2. Laparoscopy & Laparoscopic Surgery including:
    1. Laparoscopy
    2. Laparoscopy/Hysteroscopy
    3. Laparoscopy Cholestectomy
    4. Laparoscopic Hernia Repair
  3. Surgery of the Breast: Includes Repair and Reconstruction
    1. Surgery
    2. Repair and/or Reconstruction of the Breast
  4. Hernia Repair
  5. Liposuction
  6. Facial Surgery; Includes Facelift,Blepharoplasty, and Laser Resurfacing
  7. Knee Arthroscopy


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What CPT Codes are to be Reported? What ICD-9-CM Codes are to be Reported?
Please refer to Procedure Codes, Required Outpatient Surgical Procedures and Related CPT and ICD-9 CM Procedure Codes, for a detailed list of CPT codes and ICD-9-CM procedure codes required. These codes will also be periodically reviewed and updated by the Board of Health with input from affected parties and others. Because codes are sometimes modified by the federal government and others, you may wish to periodically check to see if revisions have been made to the list. You may check for revised procedure code lists by calling Virginia Health Information at 804-643-5573 or via their website at www.vhi.org.
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What is the Effective Date? When must Information be Submitted?
Procedures performed on and after November 1, 2001, are to be reported. Depending on how the information is submitted, information is due between 45-120 days from the end of the calendar quarter in which the procedure is performed. See Figure 1- Data Submission Types.
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Why are these Procedures to be Reported?
Procedures recommended were chosen based on their volume, clinical severity and actual or perceived risk to the patient. A multi-disciplinary Technical Advisory group also considered their prevalence among various age groups and gender distribution. The procedures were adopted by the Board of Health in August 2001.

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If a Physician Performs one of the Listed Procedures in an ASC or Hospital, Who is Responsible for Reporting Information?
When one of these surgeries is performed by a physician in an ASC or HOPD, reporting responsibility falls to the HOPD or ASC, not the physician. Physicians performing selected surgeries in their office are responsible for reporting.

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How will this information be used?
Data and information can be utilized to support public health studies, develop information for consumers, and for use by ambulatory surgical centers, hospitals, and physicians.
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Some of my Patients are Self-pay. I don’t Bill them Using a HCFA-1500 or UB-92. Do I have to Report these Procedures?
Yes, reporting is required for any of the selected procedures performed in an ASC, HOPD, or physician’s office.
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Fees for Submission of Data
No fees will be levied on those providing outpatient surgical data for the processing of this data for the first four quarters of submission (procedures performed November 1, 2001-September 30, 2002). For procedures performed after that date, the Board of Health may establish reporting fees.

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Processed and Verified Data
Processed and verified data is that which pass edits for 95% of all records electronically submitted by a provider. These edits will be posted on VHI’s website at www.vhi.org by December 1, 2001. Processed and verified data for all specified outpatient surgical discharges that occur in a calendar quarter must be received by VHI by 120 days following the close of the calendar quarter. Historically, any fees established by the Board of Health for filing of data have been waived by VHI when data was submitted as processed and verified. Filings that are incomplete are subject to a $25 per day fine to be levied by the VDH.
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Non-Verified Data-Electronically Submitted Data
The second option is to electronically submit data that is not processed and verified. Non-verified data has not necessarily been subjected to editing prior to submission. Because of the additional effort required to process data that is not pre-edited, non-verified outpatient procedures performed on after September 30, 2002, may be subject to a filing fee for processing if established by the Board of Health. Late fees of $25 per working day may be levied by the VDH.
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Non-Verified Data-Paper Copies of UB-92 or HCFA 1500 Forms
Until January 1, 2004, reporting entities performing fewer than 100 procedures may submit UB-92 or HCFA-1500 paper forms. Care must be taken to remove patient names and street addresses (include patient zip code only). Ensure the patient identifier (not subscriber identifier) is present as well as the primary payer (self pay must be marked as such). All copies must be legible to be accepted.

Figure 1- Data Submission Types
Type of Submission Frequency of Submission Fee Applied Notes
Processed and Verified 120 days following end of calendar quarter No fees for first four calendar quarters of data submitted (after September 30, 2002. Late fee may be levied by VDH if records are submitted late.
Non-verified, electronic submission 45 days following end of the calendar quarter May be established by Board of Health effective for procedure s performed after September 30, 2002. Late fee may be levied by the VDH if records are submitted late.
Paper Submission 45 days following end of calendar quarter May be established by Board of Health effective for procedures performed after September 30, 2002. $0.75 per record to accompany submission of records. Paper submission only allowed for reporting entities performing less than 100 of selected procedures annually. Paper submission only allowed until January 1, 2004.


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Electronic Submission
Record Layout, VHI Outpatient Record Layout, is a record layout for all electronic submissions of data. Electronic records may be sent via CD or floppy disk to VHI using the form in Attachment #4. For more information on this visit www.vhi.org.
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Records in Error
Records not passing edits, regardless of submission type, will be identified and returned to the provider. VHI produces summary reports of filing data for affected providers.

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Where to Submit Data
Outpatient surgical data will be collected and processed by Virginia Health Information (VHI). Any information submitted to the VDH will be forwarded to VHI. Attachment #4 is an Outpatient Data Cover Sheet that is to accompany any electronic or paper submission of quarterly data.

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Where May I Find More Details About the Law and Regulations?
Copies of the law as passed are available on the legislative information system. The URL for direct access to the law is: http://leg1.state.va.us. The bill was passed during the 2001 session and numbered HB2763. The draft regulations are available at www.vhi.org. You may also receive a printed version of the bill and draft regulations faxed or mailed by calling VHI at 804-643-5573.
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Co-Morbid Conditions Existing but not Treated
This field is for reporting ICD-9-CM diagnosis codes of conditions that were identified but were not treated during the surgical procedure. There is no list or expected ICD-9 codes for this field. There is no expectation that the ICD-9 codes provided in the Co-Morbid field also be reported in the diagnosis field.
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How do I report information on more than 23 revenue center codes?
Because outpatient surgery is considerably less complex than inpatient stays, it is believed that more than 23 unduplicated revenue center codes will not be necessary and VHI will not accept more than 23 revenue center codes. Continuation records will not be accepted. Facilities are advised to "roll up" duplicate or similar revenue center codes prior to submission.
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How do I report records in which more than six procedures are performed?
While occasionally more than six procedures might be performed during an outpatient surgical visit, VHI requires only information on the seven procedure family groups listed in the VHI Outpatient Data Submission Manual and on VHI's outpatient section of its website under Procedure Codes. First report any procedure codes VHI requires for reporting and then include other performed procedures for up to a total of six for both VHI-required and other procedures performed.
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