The Practice Administrator: Decoding 5010

The compliance deadline for Version 5010 of the Electronic Data Transaction standard is three months away - January 1, 2012. Our practice management/EHR software vendor is currently testing 5010 and we are beta-testing this with them. So far so good… here’s some of what we’ve learned.

Title II of HIPAA requires the U.S. Department of Health and Human Services (HHS) to establish national standards for electronic healthcare transactions and national identifiers for providers, health plans, and employers. It also addresses the security and privacy of health data. The law requires every business that does business electronically to use same health data transactions, code sets, and identifiers. HIPAA has identified 10 standard transactions for EDI (electronic data interchange) for transmission of healthcare data. Claims and encounter information, payment and remittance advice, and claim status inquiry are several of the standard transactions.

What are some of the improvements in 5010? Version 5010 standardizes business information related to the transaction and is more specific in defining what data needs to be collected and transmitted.

5010 prepares systems for International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) as a HIPAA standard for transactions. Specifically, 5010: increases the field size for ICD diagnosis codes from 5 to 7 bytes, adds a one digit version indicator to ICD code to indicate Version 9 vs. Version 10, increases the number of diagnoses codes allowed on claim, and includes additional data modification in the standards adopted by Medicare FFS (fee-for-service).

The new system also distinguishes between principal diagnosis, admitting diagnosis, external cause of injury, and patient reason visit; and addresses current unmet needs for some institutional claims (conditions present upon admission).

Here’s a short list for preparing for 5010 compliance:

Verify that your vendor is ready and possibly even start testing.

Ensure you can accommodate nine-digit billing zip for billing provider and service facility location address fields.

Verify that you are NOT reporting a P.O. Box in the billing provider address; has to be physical address.

Verify that you are reporting appropriate organization National Provider Identifier Standard (NPI) and sign-up for ERA (electronic remittance advice)/ EFT (electric funds transfer) if not.

Start testing as soon as possible.

For the most part, the activity for 5010 compliance should be behind the scenes and cause minimal disruption to your practice operations. As long as your practice management software vendor and clearinghouse are prepared, the process should be smooth. Luckily, it’s in the best interests of all of these parties to minimize problems.

The real change will come with ICD-10, which we in the U.S. are the last to adopt of all the industrialized countries. Bottom line: More than likely your vendors are already on top of it, but make sure you are ready to go so you feel no impact on your revenue cycle.

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