5010 and ICD-10

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5010 and ICD-10

• Are you preparing?

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Who are Covered Entities?

• Health care provider that conducts certain
  transactions in electronic format
• Clearinghouse
• Health plan

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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.

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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!

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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

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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)

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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 vendors schedule
• Know your trading partners schedule
• Communicate within entire organization to insure
  all impacts identified early.

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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

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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.

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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

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Structure of ICD-9 vs ICD-10

• 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-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

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ICD-10-CM Structure3 to 6 position code with
leading alpha (extension)
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5010 and ICD-10 Milestones
Target Date Activity
Jan 2009 Begin Level 1 activities (Gap analysis, design, development, internal testing)
Jan 2010 Begin internal testing for Versions 5010 D.0
Dec 2010 Achieve 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. 
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Compliance Dates

• Compliance deadlines were set per public comments
• CMS expects compliance deadlines to be met no
  extensions
• Success will depend on starting early!

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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!

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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 1-230pm 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

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EDI Addresses Numbers EDIMedicareA_at_WPSIC.com
EDIMedicareB_at_WPSIC.com

• Medicare Part A Legacy A Medicare J5 MAC Part
  A B
• (multiple states) (Iowa, Kansas, Missouri,
  Nebraska)
• WPS Medicare EDI WPS Medicare EDI
• PO Box 1602 1717 West Broadway
• Omaha, NE 68101 Madison, WI. 53713
• Fax [phone] Fax
  [phone]
• Med A Hotline [phone] J5 Hotline
  [phone]
• 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
  200
• Marion, IL 62959 Bloomington, MN 55431
• Fax [phone] Fax [phone]
• Med B EDI Hotline [phone] Phone (952)
  885-2811
• [phone]
• [phone]

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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/icd10
  cm.htm
• Washington Publishing for 5010 Technical Report
  Type 3 guides WWW.WPC-EDI.com
• CMS http//www.cms.hhs.gov/HIPAAGenInfo