If you think you can wait until 2013 to evaluate your system processes and work protocols for the ICD-10 implementation, think again! The ICD-10 implementation doesn't mean you simply need to purchase a new coding manual. It involves changes and considerations that should be initiated this year. Just for starters, did you know electronic transaction version 4010 will change to version 5010 beginning with internal testing in 2010 and external testing as early as Jan. 1, 2011? If you've just experienced a "deer in the headlights" reaction, fear not. This column will bring you up to speed.
HIPAA requires the HHS to develop standards regarding the electronic submission of health care transactions by covered entities (healthcare providers, health plans and healthcare clearinghouses).
According to CMS, approximately 99 percent of Medicare Part A claims and 96 percent of Medicare Part B claims transactions are received electronically. The current version of the standards (the Accredited Standards Committee X12 Version 4010/4010A1 for healthcare transactions) lack the infrastructure required by the healthcare industry, particularly for implementation of ICD-10.
The ICD-10 codes are seven digit alphanumeric codes which are currently not supported by the current electronic transaction standard 4010. Therefore, the format by which your claims are currently sent change to accommodate the new code set. 5010 (Version 005010 of the Accredited Standards Committee (ASC) X12 Technical Reports Type 3 -TR3s) is the next version of the HIPAA electronic transaction standards.
Despite the 2013 implementation date for ICD-10, it is imperative that providers prepare now (internal testing Level 1 began Jan. 1 and external testing Level II begins Jan. 1, 2011) for the new standards version 5010 in order to continue submitting claims electronically and to avoid delays in claim payments. Keep in mind, after Jan. 1, 2012, all electronic claims must use version 5010.
For HIPAA covered entities who electronically file claims, check patient eligibility status, or electronically receive remittance advice data, either directly to a health insurance payer or through a clearinghouse, the formats currently used must be upgraded from X12 Version 4010/4010A1 to electronic claims Version 5010. For Medicare, these HIPAA-mandated formats include the following:
- Claims (837-1, 837-P, 837-1 COB, 837-P COB, and NCPDP)
- Remittance advice (835)
- Claim status inquiry/response (276/277)
- Eligibility inquiry/response (270/271)
Version 5010 is crucial to the adoption of the ICD-10 codes and includes, for example, the following infrastructure changes from the previous Version 4010 in preparation for the ICD-10 codes:
- Increase in field size for ICD codes from five digit to seven digit alphanumeric code
- Addition of a one-digit version indicator to the ICD code to indicate Version 9 versus Version 10
- Increase in the number of diagnosis codes allowed on a claim (eight to 24 codes)
Start now or pay later
Providers should begin to prepare now for the change to assure a smooth transition to the 5010 transaction standard in order to minimize delays in processing and payment of claims.
Contact your software vendor
All providers should verify the following with their software vendors regarding transition preparations:
- Does my current system accommodate the data collection and transaction conduction for 5010?
- Will there be an additional fee for an upgrade from my current system?
- When will my system upgrade be completed and available? Note: Upgrades should be available by end of 2010 for external testing to begin in a timely manner in 2011.
Contact your clearinghouse, payors and other billing vendors
Your software vendors may be a great resource to provide you with details about what you need to do to comply with Version 5010 standards and ICD-10. Initiate communications with payors, clearinghouses or billing services and ask the follow questions:
- Will you be upgrading your systems to accommodate the 5010 transactions (ICD-10 code format)?
- When will your upgrades be completed?
- When can a test transmission be sent?
- Will you (i.e., payor) increase fees for the 5010 transactions? (Be prepared to re-negotiate electronic data interchange (EDI) contracts.)
Identify potential changes to existing work protocol
The ICD-10 codes provide a greater level of specificity and as such will require equivalent clinical reporting. Begin now to identify the following areas impacted by Version 5010 and the eventual ICD-10 implementation and plan accordingly:
- Software systems
- Electronic health records
- Forms and/or super bills
- Clinical documentation
- Quality reporting
Establish a budget
The implementation costs for Version 5010 and ICD-10 will overlap somewhat. Keep in mind there may be additional costs. Here are a few areas you may need to invest in:
- Internal system changes and testing
- Staff training
- Resource materials
- Other unforeseen costs
Identify staff training needs
When developing training for all staff members working with diagnosis coding in any form, your ASC should consider the following:
- Key players (physicians, business office support-coders, billers, collections/denials)
- Extent of training
- Method of training
- Continuing education
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ICD-10 and Version 5010 Compliance Timelines |
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HIPAA covered entities affected by the transition to Versions 5010 and ICD-10 transitions include health care providers, such as physicians, alternate site providers, rehabilitation clinics, hospitals, Health plans/carriers, clearinghouses, and business associates that use the affected transactions, such as billing/service agents and/or vendors. Here is an overview of ICD-10 compliance steps and deadline dates, according to CMS. Italicized text under the compliance are additional comments on what ASCs should be doing to meet these deadlines. |
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Date |
Compliance Step |
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January 1, 2010 |
Payers and providers should begin internal testing of Version 5010 standards for electronic claims Discussions between provider and system vendors should be ongoing during 2010. |
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December 31, 2010 |
Internal testing of Version 5010 must be complete to achieve Level I Version 5010 compliance Providers should be able to demonstrably create and receive compliant transactions by Dec. 31. Providers should complete their internal testing, and are now ready to test with external payers and partners beginning in Jan. 2011. |
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January 1, 2011 |
• Payers and providers should begin external testing of Version 5010 for electronic claims. Providers are ready to transmit in the new format, but will insurance carriers be ready to receive them?
• CMS begins accepting Version 5010 claims • Version 4010 claims continue to be accepted Communications with clearinghouses or billing services should be initiated if not already ongoing. |
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December 31, 2011 |
External testing of Version 5010 for electronic claims must be complete to achieve Level II Version 5010 compliance Completion of end-to-end testing with all partners/carriers. |
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January 1, 2012 |
• All electronic claims must use Version 5010 • Version 4010 claims are no longer accepted |
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October 1, 2013 |
• Claims for services provided on or after this date must use ICD-10 codes for medical diagnosis and inpatient procedures • CPT codes will continue to be used for outpatient services |
Resources:
- A web page dedicated to providing all the latest information for ICD10 is available by clicking here.
- New Health Care Electronic Transactions Standards Versions 5010, D.0, and 3.0 A web page dedicated to providing all the latest versions 5010 and D.0 news for all HIPPA covered entities is available on the CMS website.
- For more information on Electronic Billing and Electronic Data Interchange (EDI) transactions, visit the EDI web page on the CMS website.
- American Health Information Management Association also has good information at www.ahima.org.
Cristina Bentin can be reached at cristina@ccmpro.com. Learn more about Coding Compliance Management.