The 411 on HIPAA version 5010
One of the many things that will be affected in order to accommodate the ICD-10 codes is the format of electronic claims. CMS recently announced that it receives more than 99% of the Medicare Part A claims and more than 95% of the Part B claims electronically. Today, physicians submit electronic claims to Medicare using Accredited Standards Committee (ASC) X12N Version 4010/4010A1. Because the existing format lacks functionality for certain transactions (e.g., the ICD-10 reporting system), Version 5010/D.0 will eventually replace the current electronic claims version.
Electronic communication between physicians and payers and hospitals requires that we have standardized codes to enable the electronic exchange of certain health information.
Standards exist today for eight electronic transactions and six code sets. The transactions are:
• Health Care Claims or Equivalent Encounter Information
• Eligibility for a Health Plan
• Referral Certification and Authorization
• Health Care Claim Status
• Enrollment and Disenrollment in a Health Plan
• Health Care Payment and Remittance Advice
• Health Plan Premium Payments
• Coordination of Benefits
The code sets are:
• International Classification of Diseases, 9th Edition, Clinical Modification, Volumes 1 and 2
• International Classification of Diseases, 9th Edition, Clinical Modification, Volume 3 Procedures
• National Drug Codes
• Codes on Dental Procedures and Nomenclature
• Health Care Common Procedure Coding System
• Current Procedural Terminology, 4th Edition
The ICD-9 code sets, developed nearly 30 years ago, contain approximately 17,000 codes and can no longer be adequately expanded. The ICD-10 code sets have more than 155,000 codes to accommodate advances in diagnoses and procedures. The ICD-10 and transaction rules have long been expected and must move together, as Version 5010 was designed to be used with the ICD-10 code sets. While Medicare contractors will be ready to handle the new standards and the HIPAA 5010 claim format by January 1, 2011, the compliance date for submitting claims in the new format is not required until January 1, 2012. CMS recently released a Special Edition MedLearn Matters article SE0904 that provides a high-level overview of some of the differences between the two claim formats, with additional resources.
About the Author: Peggy S. Blue, MPH, CPC, CCS-P, oversaw the development, implementation, dissemination, and reporting of information related to Medicare professional services training efforts for Highmark Medicare Services prior to joining HCPro, Inc. In that capacity Blue has researched, resolved, and responded to issues and inquiries from the physician community in addition to congressional offices, medical societies, and professional associations. Blue has delivered multiple presentations on Medicare legislation. Blue is a member of the American Academy of Professional Coders. She holds a Master’s of Public Health from the University of Tennessee in Knoxville and a Bachelors of Art degree from Purdue University.
