Transition Information to HIPAA-AS 5010 / ICD-10:
Technical and Business Process Information

Quick Facts | Implementation Timelines Guidance | What is Changing? | High Level Challenges | Areas of Impact

The following information is valid as of March 2012; however, for more recent HIPAA compliance information please refer to The Department of Health and Human Services (HHS) at http://www.hhs.gov/ocr/privacy/.

HIPAA Compliance - Quick Facts

• The federally mandated HIPAA-AS (Administrative Simplification) standard covered electronic transactions and code sets are changing.
• On January 16, 2009, the DHHS announced the final rules for electronic transactions (version HIPAA 5010) and new code set standards (ICD-10 procedure codes).
• HIPAA compliance dates are January 1, 2012 for the updated electronic transactions and October 1, 2013 for the new ICD-10 code set standards.
• A transition period for implementing the new electronic transactions is scheduled to begin January 1, 2011 and end December 31, 2011.
• The implementation of 5010 and ICD-10 codes are intended to improve patient care quality, enhance claim processing, improve data reporting and promote increased interoperability across industry stakeholders.
• Significant impacts to provider billing and payment processing will be realized across the health care industry if stakeholders fail to collaborate, coordinate and communicate throughout this transition.

HIPAA Compliance - Implementation Timelines Guidance:

Recommended Target Dates	HIPAA Compliance Milestone
January 2009	Begin Level 1 HIPAA Compliance Activities (gap analysis; design; development; internal testing)
January 2010	Begin Internal Testing for Version 5010 (part of Level 1 Compliance activities)
December 2010	Achieve Level 1 Compliance (covered entities have completed internal testing and can now send and receive compliant transactions)
January 2011	Begin Level 2 Compliance Activities (external testing with trading partners begins; begin dual 4010/5010 processing)
January 1, 2012	Achieve Level 2 Compliance (5010 Compliance Date for All Covered Entities)
October 1, 2013	ICD-10 Coding Compliance Date for All Covered Entities

* These target dates and milestones are described in the preamble of the HIPAA 5010 final rule and are recommended for use as guidance by the health care industry for HIPAA compliance.

HIPAA-AS ICD-10 Coding Guidelines: What is changing?

• The ICD10-CM (Clinical Modifications) and ICD10-PCS (Procedure Coding Structure) are new medical code sets under HIPAA-AS and represents a fundamental overhaul of the current ICD-9 coding system to ICD-10 code.
• ICD-10 procedure codes are the new medical code sets under HIPAA-AS for diagnosis reporting and replaces ICD-9-CM.
• ICD10-PCS replaces CPT-4 and HCPCS for inpatient hospital procedure coding ONLY.
• ICD-10 codes are used to calculate payment, adjudicate coverage, compile medical statistics and assess quality of care. This means the applications have to change to accommodate the new codes for new medical procedures not covered under current ICD-9-CM code sets - Significant Effort and Time required
• The current ICD-9-CM codes sets (24K) are outdated and do not reflect advances in medical technologies nor are they descriptive enough.
• The new ICD-10 codes (CM codes and PCS code sets) will provide:
• Greater flexibility to enable future capabilities and allows for over 155K codes.
• Contain more descriptive and robust categories for precise coding, streamlined reimbursement processes and richer data quality for further analysis.
• Maximizes the value of clinical data and the business value of interoperability of e-Health initiatives and the EHR.

HIPAA-AS ICD-10 Coding Guidelines: High Level Challenges of 5010 Implementation

• Increase understanding and awareness of the technical and business process changes needed to comply with the new electronic transactions and Code Set standards (Key Point: internal & external constituents must be part of your communication and outreach program).
• A gap analysis between current state and future state is the key driver behind the identification of the work that needs to be done (Key Point: remember that there are new, deleted and modified data content across all electronic transactions)
• Engagement of external vendors and electronic trading partners (Key Point: ensure compliance interpretations are consistent and that testing and implementation timelines are realistic and attainable).
• The testing of internal business systems capabilities, business process changes and interfaces with your electronic trading partners will require communication, collaboration and coordination. (Key Point: end-to-end systems capability testing will be a major challenge to the entire health care industry; early planning is essential; 5010 test data will be problematic).
• Implementation and the dual-use transition period will require coordination between covered entities and electronic trading partners. (Key Point: not all covered entities and their electronic trading partners will be able to deploy a dual-use transition capability).

HIPAA-AS 5010 / ICD-10 Codes: Areas of Impact

• Business processes that utilize data content in the new formatted HIPAA-AS electronic transactions and code sets.
• The transition to ICD-10 procedure codes will impact the following health care processes:
  • Measuring the quality, safety and efficacy of patient care.
  • Making clinical decisions based on data obtained from multiple sources.
  • Design of payment systems and medical claim reimbursement.
  • Research studies, clinical trials and resource utilization.
  • Health policy setting across the health care industry.
  • Improving clinical, financial and administrative performance.
  • Increases in the identification of medical fraud and abusive practices.
  • Tracking public health issues and risks.
  • Providing data to "consumers" regarding costs and outcomes of treatment options.
  • Information Technology needs to be looked at including but not limited to backend Applications for Claims, Eligibility, EDI Integration tools to support the HIPAA 5010 initiative.

Additional HIPAA Compliance Services offered by EDI Specialists include:

• Mapping of HIPAA transactions / EDI transactions
• Providing HIPAA experienced QA and testing professionals

To discuss or for any questions, please contact:

Wayne Marshall
VP of Professional Services
800.821.4644 x216
wmarshall@edispecialists.com

Reprinted, by permission, "Preparing for the Future: 5010 Implementation." HFMA- Florida Chapter Conference. Web. Copyright 2010 by the HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION.