Valuset Item.Category HCX adoption

[vharish85]

Name	Valueset - Item.category
Description	Code to identify the general type of benefits under which products and services are provided.
Alternate name	Benefit Category Codes, Service Type codes
Field	https://www.hl7.org/fhir/coverageeligibilityresponse-definitions.html#CoverageEligibilityResponse.insurance.item.category, https://www.hl7.org/fhir/coverageeligibilityrequest-definitions.html#CoverageEligibilityRequest.item.category
Example Valueset (HL7,FHIR)	http://hl7.org/fhir/R4/codesystem-ex-benefitcategory.html
Example Valueset (X12)	https://x12.org/codes/service-type-codes
Example PMJAY	https://nha.gov.in/img/pmjay-files/HBP-2.1.pdf (Specialty codes used for general categorization of benefit category)
Example from ECHS	https://echs.gov.in/img/Policy/Medical/Advisory/Referral/Med7.pdf (see Specialty codes)

Proposed HCX | http://hl7.org/fhir/R4/codesystem-ex-benefitcategory.html
The proposed list from hl7 coding system is short , simple category for benefits or service specialties that could be categorized. System should be able to map all the specialties using the proposed benefit category.

Dear All,
I would like to collect your feedback here and thoughts.

@angshu , @gopi-vitraya @abhimail

[angshu]

Thanks a lot @vharish85, this is great starting point. will go through the other sts (ECHS and X12) and come back with thoughts.

[gopi-g-dev]

Thank you @vharish85 for the initiative.
Also, a point to note here is that benefit categories and medical specialties are different, though there is a big overlap. As an example, benefits such as ambulance charges, room charges, food charges, gloves, neblizers, Oxygen, etc... these are all benefits and will have to be categorized. They may not fall into any particular medical specialties in the general sense. Makes sense?

[gopi-g-dev]

@vharish85

@abhimail and I looked at the four proposals you gave for benefit item category. We agree with your suggestion to go with the FHIR valueset. The other valuesets from NHA, EDI X12 and ECHS have some overlap, but that level of granularity is not needed in most insurance plan benefits categorization.

We may mark the valueset as extensible (like many other valuesets) so that it could be extended by payers if or when they need it.

This valueset could be used at four different places:

CoverageEligibilityResponse.insurance.item.category
CoverageEligibilityRequest.item.category
InsurancePlan.plan.specificCost.category
Claim.item.category

[nvirmani]

Just wanted to clarify that this list we are seeing is an example list as labeled by them, right? Or is there a full list present somewhere? valueset

I think the eligibilityrequest and response should be at a high level, some of these seem to be going into detail in this valueset (e.g. diagnostic lab vs diagnostic dental vs diagnostic xray vs. MRI vs renal dialysis). In course of determining eligibility for users, initially requests are usually at a high level, and later get into specifics (which I think should be handled by benefits and codes). I think @ggopi-dev you're implying the same in an earlier comment?

[gopi-g-dev]

@nvirmani

1. The list is not just an example, but a starting point and could/would be extended by the HCX working group (including yourself). It is far from being comprehensive, but gives something to get started. If you have suggestions to extend the list, please do. @abhimail would help in adding them to the valueset.
2. Eligibility request could be at a high level or low level depending on what the payer supports, and I do not know how the future would look like once HCX v1 is adopted. HCX protocol may not have a say there.
3. This valueset is just about benefit item's category. The actual benefit items are more exhaustive and there is no valueset that HCX working groups are suggesting for the latter, yet. Benefit items are varied in nature - PTCA (procedure), COVID-19 (diagnosis), nursing charges (services), Drugs (goods), Cataract package (package), ambulance charges (services), sterilized goods used by a doctor in an OPD encounter like ENT exam, prostate exam, dental exam (goods), etc.... Now, all these benefits that a payer provides and the provider charges, have to be categorized as per the FHIR profiles of Insurance Plan, Eligibility Request, Eligibility Response, Claim and a few other may be. This thread is basically to identify those categories. Not the benefits themselves. I think you may have understood this already, but I just want to be clear in what this thread is purposed for.

[nvirmani]

1 - ok, was confusing because there is a line in the link for Benefit Category Codes http://hl7.org/fhir/R4/codesystem-ex-benefitcategory.html which says "this is an example set"
2 - agree that it would be at both levels, I was suggesting the same
3 - including a file we shared on another thread 7-8 days ago. There are a lot of similarities there, but reduction in what I think might be overlaps in categories.
https://docs.google.com/spreadsheets/d/1wqFWLcZO8CU_K2XT6H-72Swh13pVC0AtQKnsPnjycn0/edit#gid=0

[gopi-g-dev]

@nvirmani
Sorry for the confusion, I missed that part in the FHIR page.
Sure, please continue with your effort.
FYI - @krisaccessh from Access healthcare is also coming up with some suggestions. He will start participating in valuesets related discussions from next week.

[krisaccessh]

To start further discussions on finalizing the value set on item category, Hospitals generally use up to a three-level bifurcation of billing items in the hospital bill such as billing groups like room rent, investigation charges, OT charges, etc., billing subgroups like "X-ray charges", "MRI charges" under Investigation charges billing group and service items like "X-ray Abdomen", "X-ray Chest" under "X-ray charges" billing subgroup level. Some hospital bills show only billing group level; details in their bill whereas some others show a detailed bill up to all three levels. We may use a similar way of classification for the item category value set.

Here is the list of items (taken from IRDAI published guidelines for billing service codes) that may be considered as a starting point.
https://docs.google.com/spreadsheets/d/1PvGgWfOdhEutey7Fm8qvsZuGVUozNytR/edit#gid=62489569

Level 1 corresponds to billing group say for example Room & Nursing charges, ICU Charges, OT charges, Medicine & Consumables, Investigation Charges, Package Charges, Procedure Charges, Ambulance Charges, Professional Fees charges, and Miscellaneous Charges.
For NHA packages (from HBP 2.1 pdf)(, the first level may map to "NHA package charges" as billing group for all NHA packages
This first level of classifying billing items will map to FHIR Resources listed here:

CoverageEligibilityResponse.insurance.item.category
ExplanationOfBenefit.item.category
ExplanationOfBenefit.benefitBalance.category
CoverageEligibilityRequest.item.category
Claim.item.category
ClaimResponse.addItem.productOrService
InsurancePlan.plan.specificCost.category

Level 2 in the attached file corresponds to the billing subcategory codes which is the second level of nesting the billing items under the billing groups.
e.g. If the billing group is "Room & Nursing Charges", the billing subcategory can be "Room Charges" and "Nursing Charges"
As a second example of nesting billing subgroup items under the billing group is that for billing group "Investigation Charges", the Billing subcategory items can be classified as "CT Charges", "X-ray Charges", "MRI charges", etc.,
For NHA packages the billing subcategory can be the NHA packages like Surgery for Pediatric Cataract package
This can map to
Claim.item.detail.category
ExplanationOfBenefit.item.detail.category
ClaimResponse.addItem.detail.productOrService

Level 3 in the attached file corresponds to billing Items or packages
e.g. If the billing group is "Room & Nursing Charges" and the billingsubgroup is "Room Charges" , then the billing service items in the bill can be "Deluxe Room charges" or "General ward Charges" etc.
For NHA. level 3 will be optional and can be either the package name only or the detailed items under the package (though the items are included in the package and covered within the package cost so the individual cost of items reflected in the bill will be zero)

This can map to
Claim.item.detail.subDetail.category
ExplanationOfBenefit.item.detail.subDetail.category
ClaimResponse.addItem.detail.subDetail.productOrService

I request all of you to review this and provide inputs to finalize the item category value set

Thanks
Krishan Bhardwaj

[gopi-g-dev]

The working group has discussed the first set of group and sub-group categories for billing/claim items. https://docs.google.com/spreadsheets/d/1Ve0lSqsXlxwAutE4CY5VA-xWG3EhU8B0/edit?usp=sharing&ouid=101124255408991053007&rtpof=true&sd=true)