ICD-10 Training Camp: How to Survive the ICD-10-CM/5010 Transition

Physician practices and hospitals know a change is coming on October 1, 2013, that will dramatically impact current business processes.  The mere mention of ICD-10-CM diagnosis codes cause anxiety in the minds of coding professionals as well as practice administrators.  Implementation of the Procedural Coding System (PCS) will be a double whammy for inpatient facilities.

Life is full of changes, some daunting and others not as life-changing.  Transitioning to ICD-10 diagnosis codes will be life-changing for the medical practice and facility.  ICD-10-CM is the new generation of diagnosis and facility procedure coding (PCS).  The best approach is acceptance and a positive attitude, which should motivate each player in this process to do what is required to ensure compliance.

It’s very important to focus on your goal and the timelines for completion and implementation.  Your tasks should be undertaken one at a time in order of priority.  Focusing on one goal at a time will lead to a seamless transition.  You need focus and energy because years 2011-2013 will require time, patience and persistence -- powerful tools for achieving your goals and compliance timeframes.

5010 is a major upgrade from 4010
Transaction set 5010 is a major upgrade from transaction set 4010.  Transaction sets are specially formatted text files designed to convey claim information in a manner sufficient to allow claim adjudication.  This is a computer data upgrade and will allow the transmission of electronic data to various business partners or individual payers of health claims.  HIPAA Transaction set 4010 cannot transmit codes required for ICD-10-CM alphanumeric code structure.  The technical changes in 5010 will streamline information exchange.  Version 5010 accommodates the ICD-10 code sets, and has an earlier compliance date than ICD-10 in order to ensure adequate testing time for the industry.

The Department of Health and Human Services (HHS) issued mandatory upgrade requirements from transaction set 4010 to 5010 on January 16, 2009.  The mandatory compliance date for ANSI version 5010 and NCPDP version D.0 (pharmacy) for all covered entities is January 1, 2012. The final rule allows use of the 5010 transactions prior to the final compliance date on January 1, 2012.  This is the first step in preparing for the ICD-10 coding system.  The focus in 2011 should be transaction set 5010, both upgrading and testing transaction submission with vendors, clearinghouses, payers, etc.  The goal in 2011 should be to create and receive compliant transactions, and to accomplish this 5010 must be in place and internal/external testing must be completed.  For small health plans using Version 3.0, the compliance date is January 1, 2013 (Medicaid subrogation for pharmacy claims, known as NCPDP Version 3.0.).  Find more information at http://aspe.hhs.gov/admnsimp/index.htm.

It will be essential to assess current computer systems.  Transaction set 5010 is a programming upgrade. The method of communicating with CMS and other carriers must migrate from the current HIPAA 4010 file format standard to the HIPAA 5010 file format standard. This migration is a necessary prerequisite to ICD-10 implementation.  The transactions include: health care claims or equivalent encounter information for professional, institutional and dental services; eligibility for a health plan (inquiry and response); referral certification and authorization; health care claim status (inquiry and response); enrollment and disenrollment in a health plan; health care payment and remittance advice; health care premium payments; coordination of benefits.  The standard for pharmacy transactions includes: claims, eligibility requests and responses, referral certification and authorization, and coordination of benefits.

Health care providers, health plans and health care clearinghouses must comply with the changes to the transaction set standards.  The Centers for Medicare and Medicaid Services (CMS) has a number of educational resources on its website to assist you with a smooth conversion. For more information, visit www.CMS.gov. From CMS home page, click “Regulations and Guidance,” and under “HIPAA Administrative Simplification,” click “Versions 5010 & D.0 & 3.0.”

A significant difference between 4010 and 5010 data requirement changes the billing provider address, because a P.O. Box or lockbox address will not be allowed with this 5010 upgrade.

Identify staff training needs
In the context of the 5010 system upgrade, the team leader should identify staff training needs. Training your staff ensures that transactions continue to be submitted, received, interpreted and responded to correctly. Develop a transition and conversion plan that includes establishing a training plan. There will be glitches, and while this can be a frustrating and overwhelming situation, there are several things that you can do to address this situation and get to the root cause of the upgrade problem.  Initially a review of the entire system should be done prior to system upgrade implementation.  In other words, prevention is better than damage control.  When errors are identified, address them immediately and communicate with all members of the team to aid in problem solving.  A strategy plan and specific task assignment and accountability will minimize problems.  With any major system implementation, there is a corresponding description of operations that details out processes that need to be followed in order to be successful.

Implementation guidelines are available for IT staff and include:

  • Data elements required or conditionally required
  • Definition of each data element
  • Technical transaction formats for the transmission of the data
  • Code sets or values that can appear in selected data elements
  •  

Define an organizational EDI strategy and determine which transactions you want to process electronically using the standard formats.  Identify process changes necessary for 5010 upgrade. Reference the following website for additional information:  http://www.wpc-edi.com.

Diagnosis Codes
ICD-10-CM diagnosis codes number 68,000 and increase with application of 7th digit requirements where applicable.  This is up from approximately 13,000 ICD-9-CM diagnosis codes.

ICD-10-CM has 21 chapters, while ICD-9-CM codes cover 17 chapters in the tabular list.  The Index in ICD-10-CM is expanded but the formatting is similar to the ICD-9 index.  The detail is greater in ICD-10 and many codes have laterality as part of the code description (example, code S61.142A, Puncture wound with foreign body of left thumb with damage to nail, initial encounter).  The “A” describes an initial encounter (7th digit).

Change is on the horizon and the time to prepare is now--or better yet, yesterday.  We can weather this storm and this will be done with knowledge, training and education.  Keep your focus on the goal and compliance guidelines and establish a plan for how you will get to your destination (October 1, 2013).  We weathered the implementation of DRG (diagnosis related groups) in hospitals and we can and will sail through ICD-10 implementation.

Find additional information on ICD-10 and CMS educational resources in our recent blog post. You can also sign up for email updates from CMS. 

About the Author

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...

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