Testing 5010 with Trading Partners

When the 5010 final rule becomes effective on March 17, 2009, health plans can begin testing with willing trading partners the 5010 standard transactions alongside the current 4010/4010A1 transactions standards. The improvements in the 5010 version 835 Health Care Payment and Remittance Advice transaction (835) for all claim types may benefit both health plans and healthcare providers.

Senate Appropriations Committee S.336 & HITECH Provisions

The House of Representatives passed H.R. 1, American Recovery and Reinvestment Act of 2009, on the evening of Wednesday, January 28, 2009. The Health Information Technology (HITECH) provisions in the House bill are in Division B (Other Provisions), Title IV. The Senate is expected to take up its version of the American Recovery and Reinvestment Plan, S.336 during the first week of February. The Health Information Technology (HITECH) provisions in the similarly named Senate bill are in Title XIII.

Why ICD-10?

There were four main reasons that the federal government moved to ICD-10 as a code set standard: (1) ICD-9 dates to 1979 and its functionality has been “exhausted” and does not reflect “new and changing medical advancements”; (2) Parts of the ICD-9-CM were full, which required putting codes in “topically unrelated chapters,” burdensome for healthcare providers in a move toward more efficiency; (3) Insufficient detail opportunities: “[I]n an age of electronic health records, it does not make sense to use a coding system that lacks specificity and does not lend itself well to updates…

Classification Coding Systems

ICD-10 diagnosis and procedure codes are “classification coding systems” useful for conducting administrative transactions. SNOMED-CT® (Systematized Nomenclature of Medicine–Clinical Terms) is a “clinically complex terminology standard” designed for the primary documentation of clinical care that will enhance interoperability with electronic health record (EHR) systems.

Migrating to ICD-10

Under the final ICD-10 rule, all healthcare providers will utilize ICD-10-CM to code diagnoses beginning October 1, 2013. For procedure coding under the final ICD-10 rule, physicians and all healthcare providers other than inpatient hospitals will continue to use the current procedure coding standard: Current Procedural Terminology, 4th Edition (CPT-4) and the Healthcare Common Procedure Coding System (HCPCS). Inpatient hospital services procedures will be coded using ICD-10-PCS codes, which provide facility related procedure codes suitable to inpatient environments.

HIPAA Administrative Simplification: Modifications to Medical Data Code Set Standards to Adopt ICD-10-CM and ICD-10-PCS

The final rule adopts modifications to two code set standards in the Transactions and Code Sets final rule that required compliance by covered entities on or after October 16, 2003. The new final rule, published in the Federal Register on January 16, 2009, modifies standard medical data code sets for coding diagnoses (ICD-10-CM) and inpatient hospital procedures (ICD-10-PCS). ICD-10-CM means International Classification of Diseases, 10th Revision, Clinical Modification for diagnosis coding, including the Official ICD-10-CM Guidelines for Coding and Reporting, as maintained and distributed by the U.S. Department of Health and Human Services (HHS).

Companion Guides

HHS notes that “the improvements to Version 5010 should minimize dependence on companion guides… and “strongly discourage[s] health plans from having companion guides unless they are focused significantly on the basics for continuity, trading partner arrangements, and use of situational data elements…. [I]f companion guides contradict the implementation guides, the transaction will not be compliant.” [74 FR 3307-3308]

Dual Use of Existing Standards

Note that HHS permits the dual use of existing standards (4010/4010A1 and 5.1) and the new standards (5010 and D.0) from the March 17, 2009, effective date until the January 1, 2012 compliance date, to facilitate testing and subject to trading partner agreement.

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