5010 compliance: You get 90-day reprieve

November 30, 2011

If your office isn’t prepared to submit claims using version 5010 electronic transaction standards, take a breath but keep on working. With so many of your fellow physicians in the same position, the Centers for Medicare and Medicaid Services has decided to wait until March 31 to begin enforcing adherence to the standards. Some caveats apply, however.

If your office isn’t prepared to submit claims using version 5010 electronic transaction standards, take a breath but keep on working.

Based on industry feedback that a majority of entities covered by the Health Insurance Portability and Accountability Act (HIPAA) would not be able to meet the January 1 compliance deadline, the Centers for Medicare and Medicaid Services’ (CMS’) Office of E-Health Standards and Services(OESS) has decided to wait until March 31 to begin enforcing adherence to the standards, the agency said in a statement. The official compliance deadline remains January 1, however.

“Feedback indicates that the number of submitters, the volume of transactions, and other testing data used as indicators of the industry’s readiness to comply with the new standards have been low across some industry sectors,” according to the agency. “OESS has also received reports that many covered entities are still awaiting software upgrades.”

The OESS’ readiness assessment echoes the results of a survey released in October by the Medical Group Management Association. That survey found that 76.8% of respondents had heard from their practice management system software vendors regarding the transition to 5010, 35% had begun internal testing, and 21.7% had not yet scheduled internal testing with their vendors. Among respondents, 4.5% said their 5010 implementation was complete, 50% said it was 26% to 99% complete, and 40% said it was less than 25% complete.

The OESS encourages all covered entities to continue working with their trading partners to adhere to the new HIPAA standards and to determine their readiness to accept the new standards as of January 1. Although the office will not enforce the standards for 90 days past the deadline, it will continue to accept compliance-related complaints during the grace period. On request, covered entities must produce evidence of adherence or a good faith effort to become compliant with the new HIPAA standards.

CMS maintains that version 5010 standards represent significant improvement over the current standards. “Version 5010…provides more functionality for transactions such as eligibility requests and healthcare claims status,” according to the agency. “Implementation of version 5010 also is a prerequisite for using the updated ICD-10 CM diagnosis and ICD-10-PCS inpatient procedure code set in electronic health care transactions effective October 1, 2013.”

Professional groups have conveyed differing opinions on the 2013 date for implementation of ICD-10 (formally known as the International Classification of Diseases and Related Health Problems, 10th revision). The American Medical Association (AMA), for example, says it will “create significant burdens on the practice of medicine with no direct benefit to individual patients' care,” whereas the American Health Information Management Association has expressed “disappointment” in the AMA’s stance, maintaining that implementing ICD-10 will have “countless benefits,” among them conformance to international standards and alignment with meaningful use incentive programs and value-based reimbursement.

The new code set for medical diagnoses, which contains about 69,000 codes, will replace ICD-9, which has 14,000 codes. Use of ICD-10 began outside of the United States in 1994. ICD-11 is expected in 2015.

Links to information on version 5010 and ICD-10 are available on the CMS Web site at http://www.cms.gov/ICD10.

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