Transaction set 5010 computer upgrade has a compliance deadline of January 1, 2012. Any entity filing HIPAA-compliant electronic transactions must have completed internal and external testing using 5010 standards; this includes claims submission, remittance advice, eligibility, claims status, referrals, authorizations, etc. The ANSI 5010 upgrade will replace the existing 4010/4010A1 version of HIPAA transactions and supports more complex activities and fixes many concerns with 4010. If you enter data into the computer and file claims electronically today, that same information and the responses you receive will change with version 5010 in many instances. Greater detail and consistency will be obtained with this upgrade but probably not without episodic tension-type headaches (G44.219) on the not so good days.
Unlike the current Version 4010/4010A1, Version 5010 accommodates the ICD-10 codes and must be in place first before the changeover to ICD-10 on October 1, 2013. A key step in preparing your office for this upgrade is testing transactions in the new version 5010 format. If you have not already done so, you should begin external version 5010 testing now, or even better, yesterday. Testing transactions using version 5010 standards will assure that you are able to send and receive compliant transactions effectively. Testing will also allow you to identify any potential issues and address them in advance of the January 1, 2012, compliance date.
Avoid rejections or delays in claim reimbursement
If providers do not conduct electronic health transactions using Version 5010 as of January 1, 2012, rejections or delays in claim reimbursement will result. It is in the best interest of vendors to be prepared for 5010/ICD-10, though they may differ in their approaches. Therefore, early communication with vendors is essential. It is imperative that vendors provide information and products that will ensure compliance with ICD-10 by the 2012 and 2013 deadlines. This requires the capability to perform internal and external testing. By November of this year, external testing should be nearing completion; if it is not, your days are numbered and undue stress is inevitable.
Version 5010 formats for the following transactions should be reviewed for changes and additional information requirements:
• Claim (837-I, 837-P, 837-I COB, 837-P COB, NCPDP)
• Payment and Remittance Advice (835)
• Claim Status Inquiry/Response (276/277)
• Eligibility Inquiry/Response (270/271)
• Referral Certification and Authorization (278)
• Enrollment and Disenrollment in a Health Plan (834)
If you are prepared to send and receive 5010/D.0 transactions and any of your clearinghouses or payers are also ready, you can begin to use them if you mutually agree to it. No one is required to begin using the transactions prior to the compliance deadline. If your practice is already sending and receiving claims via 5010, you deserve credit for being on top of your game.
Ask yourself: Where is my practice today?
So ask yourself: Where am I today? Where do I want to be on January 1, 2012, and, how do I get there? After December 31, 2011, HIPAA covered entities cannot use Versions 4010 and 5.1 regardless of date of receipt or date of service on the electronic claim. As of Jan. 1, 2012 all HIPAA covered entities must be in full compliance with Version 5010/D.0 exclusively. Compliance with this deadline is just the beginning because you must monitor your electronic transactions to ensure accurate processing and reimbursement. Address issues as soon as they are identified–take a proactive approach. Monitor the CMS website for updated information and instructions.
The ICD-10 transition is a team effort, not a one-person job. Identify the skills, knowledge and experience necessary for a successful implementation. Assessments of staffing levels, knowledge and capabilities can help prepare for both immediate and future needs.
The next deadline for final implementation of ICD-10 code sets is October 1, 2013, as you know from my previous columns. ICD-10 affects all aspects of health care. Each organization must manage the transition according to its unique business needs and functions. Since there is no “one-size-fits-all” solution, it is vital to maintain frequent and consistent communication between providers, health plans and vendors. This way, difficulties that may arise can be remedied sooner rather than later.
Physicians should be included when planning implementation strategies and educational focus to ensure a successful transition. Communication is the exchange and flow of information and ideas from one person to another, and another, flowing in both directions. Feedback is essential, with everyone working toward the final goals: compliance and meeting set deadlines. Knowledge of code sets is essential during this change. A “Code Set” is any set of codes used for encoding data elements such as medical concepts, diagnoses (ICD-10-CM) or procedures (ICD-10-PCS). Non-medical codes sets are things such as zip codes, administrative billing codes, etc.
We are in the final countdown to compliance deadline January 1, 2012. On this date we go live with transaction standards 5010. Implementation of any computer update is stressful, but we meet stress every day as we go about our daily tasks. We deal with laws and transmittals that change on a regular basis, we adapt. Coders will accommodate themselves to the new requirements; they will adjust their behavior and daily routines to the new rules. Everyone will survive this mandate and eventually it will become business as usual.
Note: Kareo customers do not need to be concerned about testing for 5010, as Kareo is conducting the testing for our customers. The 5010 update will be included in an upcoming release at no extra charge. For more information on Kareo’s 5010 readiness, see “Will Kareo Customers Be Ready for 5010? Of Course!“
Nancy Maguire, ACS, PCS, FCS, HCS-D, CRT, author of The Nancy Maguire GPS to ICD-10-CM Planning and Implementation Guide, is a nationally-renowned procedural and diagnostic coding instructor, bootcamp trainer, and workshop leader. She has spent more than 30 years as a hands-on coder and has authored countless coding articles and presentations. In her expansive career, she has transitioned from nursing, to coding, to practice management, auditing and consulting. Nancy served as Director of Coding and Reimbursement at UTMB in Galveston Texas for four years. She served the first two terms as president of AAPC in the early 1990s.
Hear Nancy speak in two complimentary archived webinars on ICD-10 presented by Kareo medical billing software: How to Prepare for ICD-10/5010 to Reduce F41.1 (Anxiety Reaction) or Preparing for ICD-10-CM: The Nitty-Gritty of Diagnosis Coding.
