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carolSpencerStarting in July 2011, the Centers for Medicare & Medicaid Services intend to launch the electronic submission of medical documentation (esMD) two-year pilot project (http://www.cms.gov/ESMD/).




By September 2011, providers may begin submitting medical documentation in the esMD X12 (275 claims attachment) format. (Note that provider participation is completely voluntary.)


Three of the four Medicare Recovery Audit Contractors (regions A, B and D) will begin participating in the esMD project in July 2011 as will the Comprehensive Error Rate Testing (CERT) contractor. Beginning December 2011, several more MACs and durable medical equipment MACs as well as the region C RAC will join the effort.


Embracing the Electronic


On its web site, CMS has a section listing two “lessons” it learned from a pre-esMD pilot project:

  • Not all of the information at the provider site is electronic; and
  • Not all of the data is in one provider system.

The agency esMD team is attempting to structure the current pilot to accommodate these provider realities. To address the first finding (first bullet above), CMS’s electronic gateway will accept medical document in PDF or TIFF format. To address the second, it will accept multiple submissions of documents for each case.


Currently, as many of you well know, RACs and others request medical documentation by sending a paper letter. Providers have two options for submitting the requested records: mail back paper copies or send via fax. If the pilot achieves what CMS wants it to achieve, providers will be able to send documentation electronically.


The pilot involves two phases. In phase one, Medicare review contractors will continue to send paper-mail requests. Participating providers will have the option to electronically return supporting medical documentation. In phase two (sometime in 2012), both the contractor requests and provider responses will be entirely electronic.


Making it Happen


CMS hired Maryland-based Quality Software Services, Inc (QSSI) (http://www.qssinc.com/esmd/index.html) to build its electronic gateway. To do so, QSSI will use the Nationwide Health Information Network (NHIN), CONNECT-compatible gateways (www.connectopensource.org), which, says CMS, will keep the documentation secure as it moves back and forth between providers and requesting contractors.


The NHIN, explains CMS, is a set of standards, protocols, legal agreements, and specifications that a consortium of health information organizations have agreed are necessary for secure and private exchange of health information over the internet. The Office of the National Coordinator (ONC) for Health IT oversees the NHIN.



Bringing Providers On-Board


To send medical documentation electronically, providers must obtain access to a CONNECT-compatible gateway. Those that want to electronically submit documentation to a RAC or other contractor must either build this gateway or procure gateway services from the health information handler (HIH) of choice.


Although some large providers, such as hospital chains, may choose to build their own gateways, CMS anticipates that many providers will choose to obtain services by entering into contract or other arrangement with a HIH. This could be achieved by contacting the HIHs that have already built an esMD gateway (available on the CMS web site) or contacting HIHs with whom providers already have relationships (such as their claims clearinghouses).


About the Author


Carol Spencer, RHIA, CHDA, CCS, is a senior consultant with Medical Learning, Inc. (MedLearn®) in St. Paul, Minn. She brings more than 20 years of experience in health information management, coding, teaching, data quality and revenue integrity. She is an accomplished local, regional, and national speaker and author covering topics such as recovery audit contractors (RACs), payment audits, MS-DRG reimbursement systems, ICD-9-CM coding, and is an AHIMA-approved ICD-10-CM/PCS Trainer. Ms. Spencer is a thought-leader in data analytics and an expert on compliance in coding, query, and clinical documentation improvement strategies.

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