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. “Correct implementation of the X12 835 will reduce phone calls to health plans, reduce appeals due to incomplete information, eliminate unnecessary customer support, and reduce the cost of sending and processing paper remittance advices” [74 Federal Register 3298]. Remember, use of the 5010 version 835 transaction standard “in advance of the mandatory compliance…


Senate Appropriations Committee S.336 & HITECH Provisions

US SENATE APPROPRIATIONS COMMITTEE Senate Bill S.336 Recommendations for Discretionary Appropriations and Mandatory Appropriations to Assist in the Economic Recovery of and Reinvestment in America AGENCY: Appropriations Committee, US Senate, 111th Congress. ACTION: Bill. Download (Requires Acrobat Reader)

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…Emerging health care technologies, new and advanced terminologies, and the need for interoperability amid the increase in…


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. According to the preamble of the proposed ICD-10 rule published on August 22, 2008, “The benefits of using SNOMED-CT® increase if it is linked to a classification system such as ICD-10-CM and ICD-10-PCS for the purpose of generating health information that is necessary for statistical analysis and reimbursement. The use of both SNOMED-CT® and ICD-10-CM and ICD-10-PCS brings value to the development of interoperable electronic health…


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

Standards. 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). ICD-10-PCS means International Classification of Diseases, 10th Revision, Procedure Coding System for inpatient hospital procedure…


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.

New HIPAA Standard Transaction Rules Released

On Friday, January 16, 2009, the Office of the Secretary of the Department of Health and Human Services published in the Federal Register final rules pertaining to: Health Insurance Reform; Modifications to the Health Insurance Portability and Accountability Act (HIPAA) Electronic Transaction Standards (74 Federal Register 3295-3328); and, HIPAA Administrative Simplification: Modifications to Medical Data Code Set Standards to Adopt ICD-10-CM and ICD-10-PCS (74 Federal Register 3328-3362).

5010 Testing

HHS recommends that the first of two testing levels of Version 5010 and D.0 begin now for all covered entities to achieve compliance beginning January 1, 2012. HHS expects no contingency period beyond that date and may impose civil penalties for non-compliance.