5010 and ICD-10

Are you preparing?

Who are Covered Entities?

Health care provider that conducts certain transactions in electronic format

Clearinghouse Health plan

What is 5010? 5010 is an electronic data interchange version of the

ANSI X12 formats for all HIPAA financial and administrative transactions for claims, remittance advice, eligibility, and claim status query and response transaction, plan enrollment, and referral authorization transactions

5010 will be the format that will allow the exchange of the larger size of ICD-10 code set

5010 must be implemented in order to implement ICD-10 code sets.

5010 The implementation of 5010 aka HIPAA2, is

rapidly approaching 5010 will be the new HIPAA format Medicare contractors will begin testing with

submitters as early as January 2011 The 5010 formats must be used as of January

2012 It is important that you discuss your 5010

preparations and readiness with your vendor and/or clearinghouse

Medicare does not anticipate any extension on the 2012 compliance date.

January 2012 is quickly approaching!

Why 5010? Current HIPAA ASC X12 Transactions

Published over 8 years ago Implemented over 6 years ago

Hundreds of industry requested changes were received and processed via the Designated Standards Maintenance Organizations (DSMO)

Approximately 500 resulted in changes to subsequent version(s) A significant number of industry requested changes were submitted

directly to the X12N Work Groups Subrogation Ambulance Anesthesia Condition Codes More

Fixed Imperfections from previous guide■ Ambiguity■ Removed content not used■ Supported the NPI regulation■ Introduced consistency

Affected Business Processes Claims (837 Institutional, Professional, and

Dental) Claim Status (276/277) Claim Payment (835) Enrollment (834) Premium Payment (820) Eligibility (270/271) Referrals and Prior Authorizations (278) Claims Acknowledgements (277CA) Acknowledgement for Health Care Insurance

(999)

Are you preparing for 5010? Start now Ask your vendor and/or clearinghouse about their plans

and timeframes implementing 5010 4010A1 to 5010 gap analysis – identify:

New content Deleted content Modified content Impact to business needs

Communicate and coordinate Test: internally and externally Know your vendor’s schedule Know your trading partner’s schedule Communicate within entire organization to insure all

impacts identified early.

ICD-10 Timeframes

NPRM Published August 22, 2008 with comments by October 21,

2008

Final rule Published January 16, 2009

Compliance date OCTOBER 1, 2013

for all covered entities with no exceptions

Why ICD-10? Improve accuracy and efficiency of coding Reduce training effort Improve communication with physicians Completeness - All substantially different procedures

have a unique code Expandability - The structure of the system allows

incorporation of new procedures as unique codes Standardize terminology - Includes definitions of the

terminology used. While the meaning of specific words can vary in common

usage, ICD-10-PCS defines a single meaning for each term used in the system.

Preparing for ICD-10 More complete than ICD-9-CM, greater

specificity Easy to expand the system Multi-axial structure makes it easier to analyze Standardized terminology makes it easier to use

once the coder has initial training Initial training time will be a factor since it

differs significantly from ICD-9-CM Having all terms defined makes it easier to teach Once basic knowledge is acquired, the coder does not

use the index

Structure of ICD-9 vs ICD-10

ICD-9 3-5 characters First character is numeric

or alpha (E or V)

Characters 2-5 are numeric

Always at least 3 characters

Use of decimal after 3 characters

Alpha characters are not case-sensitive

IDC-10 3-7 characters Character 1 is alpha Character 2 is numeric Characters 3-7 are alpha

or numeric All letters except U Always at least 3

characters Use of decimal after 3

characters Alpha characters are not

case-sensitive

ICD-10-CM Structure:3 to 6 position code with leading alpha (+extension)

5010 and ICD-10 Milestones

Target Date

Activity

Jan 2009Begin Level 1 activities (Gap analysis, design, development, internal testing)

Jan 2010 Begin internal testing for Versions 5010 & D.0

Dec 2010Achieve Level 1 compliance (Covered entities have completed internal testing and can send and receive compliant transactions)

Jan 2011

- Begin Level 2 testing period activities (external testing with Trading Partners and move into production; dual 4010A/5010 processing mode)- Begin initial ICD-10 compliance activities (Gap analysis, design, development, internal testing)

Jan 1, 2012

5010/D.0 Compliance Date for all covered entities.

Oct 1, 2013

The Compliance date for ICD-10-CM and ICD-10-PCS is October 1, 2013 for all covered entities. 

Compliance DatesCompliance Dates

Compliance deadlines were set per public comments

CMS expects compliance deadlines to be met – no extensions

Success will depend on starting early!

Our Message to You… Start preparing now! Work with your vendor and/or clearinghouse. It is your responsibility to be compliant. CMS expects compliance deadlines to be met –

no extensions.

If you fail to prepare, it will be your business and cash flow that will be affected!

EDI Ask The Contractor Teleconference (ACT) These teleconferences are to address your EDI

questions. No reservations are required. Who should attend? Providers, billing staff,

vendors and clearinghouses with Medicare EDI questions.

2010 calls (all times 1-2:30pm cst):Date Dial In ID

May 13, 2010 800-305-2862 35459364 July 8, 2010 800-305-2862 35459365 September 9, 2010 800-305-2862 35459366 November 11, 2010 800-305-2862 35459367

EDI Addresses & Numbers EDIMedicareA@WPSIC.com EDIMedicareB@WPSIC.com

Medicare Part A Legacy A Medicare J5 MAC Part A & B(multiple states) (Iowa, Kansas, Missouri, Nebraska)WPS Medicare EDI WPS Medicare EDIPO Box 1602 1717 West BroadwayOmaha, NE 68101 Madison, WI. 53713Fax: (402) 351-6188 Fax: (608) 223-3824Med A Hotline: (866) 734-6656 J5 Hotline: (866) 503-9670

Medicare Part B Legacy Medicare Part B Legacy(Illinois, Michigan, Minnesota, Wisconsin) (EFT)WPS Medicare Electronic Data Services WPS Medicare Electronic Data

Services 912 N Pentecost Drive 8120 Penn Ave. S., Suite 200Marion, IL 62959 Bloomington, MN 55431Fax : (618) 998-5170 Fax: (952) 885-2899Med B EDI Hotline: (877) 567-7261 Phone: (952) 885-2811

(952) 885-2881 (952) 885-2882

Resources General ICD-10 information

http://www.cdc.gov/nchs/about/major/dvs/icd10des.htm ICD-10-CM files, information, and General Equivalence

Mappings (GEM) between ICD-10-CM and ICD-9-CM

http://www.cdc.gov/nchs/about/otheract/icd9/icd10cm.htm

Washington Publishing for 5010 Technical Report Type 3 guides: WWW.WPC-EDI.com

CMS: http://www.cms.hhs.gov/HIPAAGenInfo