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Implementing New HIPAA Transactions Version 5010

Implementing New HIPAA Transactions Version 5010. Now Is The Time!. Final Rules Issued To Change HIPAA Standards. On January 16, 2009 HHS published 2 Final Rules One upgrading X12 and NCPDP HIPAA administrative transactions, with a January 1, 2012 compliance date

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Implementing New HIPAA Transactions Version 5010

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  1. Implementing New HIPAA Transactions Version 5010 Now Is The Time!

  2. Final Rules Issued To Change HIPAA Standards On January 16, 2009 HHS published 2 Final Rules • One upgrading X12 and NCPDP HIPAA administrative transactions, with a January 1, 2012 compliance date • One replacing ICD-9-CM with • ICD-10-CM for diagnoses • ICD-10-PCS for inpatient hospital procedures • With an implementation date of Oct 1, 2013 for the change (services provided on or after that date) • That was two years ago!

  3. Transaction Standard Upgrades(Why Change?)

  4. A New Version of HIPAA Standards • Not a brand new set of standards, but an “upgrade” • Developed in response to numerous suggestions over the years since initial HIPAA implementation • Allows for the use of ICD-10 codes which must be used for services on and after Oct 1, 2013.

  5. Dual Use Period • Final rules for transactions allow use of either old or new standard until the Jan 1, 2012 compliance date • “Willing trading partners” can move to the new standards before the compliance date – you cannot be forced to move. • Means a spread out testing and transition period, easier for the industry. • Must use by Jan 1, 2012.

  6. What Do New Standards (Version 5010) Bring • Improvements for business • Clarity and consistency in instructions for use of each transaction • More uniformity in situations to minimize differences in usage among health plans – fewer “companion guides”.

  7. What Does 5010 Bring • Claims • Enables use of POA indicator • Separates diagnosis code reporting • Clarifies use of NPI • Lowest level of granularity for all reporting • Eliminates “pay-to” provider, must pay to billing provider; • Required minutes for anesthesia as opposed to units or minutes • Provides greater consistency between dental and professional claims.

  8. What Does 5010 Bring • Remittance advice • Clarifies rules for use • Improves balancing • Can be used with 4010 claims • Includes medical policy segment – explains why claims denied • Enrollment/Disenrollment • Improves privacy protection • Adds information such as enrollment subtotals and coverage reasons

  9. What Does 5010 Bring • Premium Payment • Allows for additional payment deductions • Premium remittance detail information now required • Eligibility inquiry/response • Adds required benefit categories and service type codes – more specific information by service type • Clarifies dependent and subscriber relationships

  10. What Does 5010 Bring • Referral/Authorization Certification • Adds necessary functionality for use • Specific information on conditions • Number of occurrences • Separate segments for key patient conditions • Supports and expands authorization exchanges • Will allow use of this transaction to meet business needs.

  11. What Does 5010 Bring • Claims Status Inquiry/Response • Allows prescription number reporting • Eliminates sensitive information to satisfy privacy concerns • Instructions for batch and real time use • Coordination of Benefits • Improves instructions and eliminates many ambiguities in creating the transaction

  12. Implications • Better information on electronic transactions • Transactions more useful for business purposes • May be able to automate certain functions • Should encourage more use of eligibility and remittance advice transactions • You can start using the better transactions soon!

  13. “The Errata” • After publication, some technical issues arose with the standards. • The standards organization (X12) fixed the standards by publishing Errata additions to the standards. • These were relatively small fixes, but they must be put in place by the Jan 1, 2012 deadline. • These fixes are now part of the standards.

  14. The Jan 1 2012 Deadline is Real • CMS has insisted that there will be no extensions of the deadline. • Medicare will start testing with providers in Jan 2011, but without the errata • Medicare will start testing with the errata on April 1, 2011. • Expected that most other health plans will follow suit. • Only the new standards will be used Jan 1, 2012 and after. Providers must be ready or face payment delays in Jan 2012.

  15. Implementation • Training • Install the software • Need time for testing • Make the business changes • Test, test, test. This is your income! • Test with as many trading partners as possible before you move into production. • Implement the changes • Check the impact

  16. Key Questions to Ask Vendors • When will you be upgrading my system to handle the 5010 version of the HIPAA transactions? • Which transactions do you support? (claims, remittance, claims status, eligibility, prior authorization) • How have you tested your software to assure that it works? • Will I be able to continue sending the older version (4010A1) of the transactions to health plans until they convert, as well as sending the new version to those health plans that can already accept it? • How long will it take to be trained on the new software? Is that included in the upgrade price?

  17. Key Questions for Vendors • What changes in my business processes do I need to make to accommodate the new transactions? • Will your software electronically interface with my EHR? • What support will you provide after installation? • Have the Errata changes already been made in your software? If not, when will they be made? • What are your plans for implementing ICD-10, the Health Plan ID, and Operating Rules?

  18. Key Questions for Health Plans • What is your schedule for upgrading to Version 5010? • Do you have a companion guide available? • When can I start testing? • What happens if I am not ready by Jan 1, 2012? • What materials do you have available to help me?

  19. Resources • CMS • Medicare web site, conference calls, contractors • WEDI • Web site (www.wedi.org), conferences, audiocasts • AMA, State Medical Societies • Health plan web sites

  20. ICD-10

  21. So What Is the Big Deal with ICD-10? • Codes change every year anyway • Transaction version changes (X12 version 5010) will be in place to handle the codes • Why not business as usual? Nachimson Advisors, LLC

  22. Major changes from ICD-9 to ICD-10 • Not just the usual annual update • ICD-10 markedly different from ICD-9 • Requires changes to almost all clinical and administrative systems. • Requires changes to business processes. • Changes to reimbursement and coverage. • Why? Nachimson Advisors, LLC

  23. Specific Changes • Diagnosis Codes (ICD-9 to ICD-10-CM) • Goes from 5 positions (first one alphanumeric, others numeric) to 7 positions, all alphanumeric • From 13,000 existing codes to 68,000 existing codes • Much greater specificity Nachimson Advisors, LLC

  24. Structure of ICD-10 Nachimson Advisors, LLC

  25. Examples of ICD-10-CM Specificity • Diabetes mellitus codes are expanded to include the classification of the diabetes and the manifestation. The category for diabetes mellitus has been updated to reflect the current clinical classification of diabetes and is no longer classified as controlled/uncontrolled: • E08.22, Diabetes mellitus due to an underlying condition with diabetic chronic kidney disease • E09.52, Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene • E10.11, Type 1 diabetes mellitus with ketoacidosis with coma • E11.41, Type 2 diabetes mellitus with diabetic mononeuropathy1 Nachimson Advisors, LLC

  26. Examples of ICD-10-CM Specificity • ICD-9-CM 599.7 Hematuria (blood in urine) • ICD-10-CM • R31.0 Gross hematuria • R31.1 Benign essential microscopic hematuria • R31.2 Other microscopic hematuria • R31.9 Hematuria, unspecified Nachimson Advisors, LLC

  27. Examples of ICD-10 Specificity • Sports injuries now coded with sport and reason for injury – • ICD-9 code - Striking against or struck accidentally in sports without subsequent fall (E917.0) • 24 ICD-10-CM Detail Codes Nachimson Advisors, LLC

  28. Examples of ICD-10 Specificity • W21.00 Struck by hit or thrown ball, unspecified type • W21.01 Struck by football • W21.02 Struck by soccer ball • W21.03 Struck by baseball • W21.04 Struck by golf ball • W21.05 Struck by basketball • W21.06 Struck by volleyball • W21.07 Struck by softball • W21.09 Struck by other hit or • thrown ball • W21.31 Struck by shoe cleats • Stepped on by shoe cleats • W21.32 Struck by skate blades • Skated over by skate blades • W21.39 Struck by other sports • foot wear • W21.4 Striking against diving • board • W21.11 Struck by baseball bat • W21.12 Struck by tennis racquet • W21.13 Struck by golf club • W21.19 Struck by other bat, racquet or club • W21.210 Struck by ice hockey stick • W21.211 Struck by field hockey stick • W21.220 Struck by ice hockey puck • W21.221 Struck by field hockey puck • W21.81 Striking against or struck by football helmet • W21.89 Striking against or struck by other sports equipment • W21.9 Striking against or struck by unspecified sports equipment Nachimson Advisors, LLC

  29. Specific Changes • Enables laterality (right vs left designations) • Restructures reporting of obstetric diagnoses • In ICD-9-CM, the patient is classified by diagnosis in relation to the episode of care. • In ICD-10-CM the patient is classified by diagnosis in relation to the patient’s stage of pregnancy Nachimson Advisors, LLC

  30. Issue – No Clear Mapping • Not always one ICD-9 to many ICD-10s • Need more specific information to go from ICD-9 to 10 • NCHS has published “GEMs”, general equivalence tables. • Not a clear map Nachimson Advisors, LLC

  31. Specific Changes to Procedure Code Reporting (ICD-9-CM to ICD-10-PCS) • New Code Set for ICD-10 • A US creation not used anywhere else • Change from 5 to 7 positions • Each position has a specific meaning. • Only used for inpatient hospital procedures • However, physician documentation for procedures will be a critical element. Nachimson Advisors, LLC

  32. Structure of ICD-10 PCS Nachimson Advisors, LLC

  33. Example of PCS Code • ICD-9-CM (sample code) • 47.01 Laparoscopic appendectomy • ICD-10-PCS (sample code) • Laparoscopic appendectomy 0DTJ4ZZ • 0 - Medical and Surgical Section • D - Gastrointestinal system • T - Resection (root operation) • J - Appendix (body part) • 4 - Percutaneous endoscopic (approach) • Z - No device • Z - No qualifier Nachimson Advisors, LLC

  34. Why Make the Changes? • Modernize Terminology • Increased information for public health, biosurvellience, quality measurement • ICD-9-CM running out of codes Nachimson Advisors, LLC

  35. Why Does This Matter? • Diagnoses and procedure codes impact virtually every system and business process in plan and provider organizations, with significant impacts on reimbursements. Nachimson Advisors, LLC

  36. Provider Impacts Documentation of diagnoses and procedures • Codes must be supported by medical documentation • ICD-10-CM codes are more specific • Requires more documentation to support codes • Expect a 15% increase in documentation time (per AAPC) • Revenue Impacts of specificity • Denials • Additional Documentation Nachimson Advisors, LLC

  37. Provider Impacts Coverage and payment • New coding system will mean new coverage policies, new medical review edits, new reimbursement schedules • Changes will be made to accommodate increase specificity • May need to discuss changes with patients Nachimson Advisors, LLC

  38. Provider Impacts Contracts with plans • Coding more specific and includes severity • Renegotiations will be based on new coding, coverage, and reimbursement • Difficult to measure what the changes will mean to overall reimbursement. Nachimson Advisors, LLC

  39. Provider Impacts Billing and eligibility transactions • Updated transactions include support for ICD-10 • New codes mean more specificity • How smooth the transition? • Expect increased reject, denials, and pends as both plans and providers get used to new codes. Nachimson Advisors, LLC

  40. Provider Impacts Laboratory orders • Will need specific ICD-10-CM codes for laboratory orders • Expect coverage changes • Need to support the tests ordered Nachimson Advisors, LLC

  41. Provider Impacts Quality Measures/P4P • New measures need to be determined based on ICD-10-CM codes • Must renegotiate with provider groups • Difficult to measure impact of change – is it because of code set or because of changes in underlying practice Nachimson Advisors, LLC

  42. Health Plan Impacts • Contracting with providers and employers • Coverage determinations • Payment determinations • Medical review policies • Plan structures • Statistical reporting • Actuarial projections • Fraud and abuse monitoring • Quality measurements Nachimson Advisors, LLC

  43. Expected Implementation and Operational Steps • Training – not just coders. • Providers • Administrative Staff • Systems Staff • Business Process Analysis • Where do you use diagnoses/inpatient hospital procedures? • What are the interfaces that may need to be changed? • What databases need to be changed? Nachimson Advisors, LLC

  44. Expected Implementation and Operational Steps • Budgeting • Resource Allocation • Vendor discussions • Workplan • Impact on other initiatives Nachimson Advisors, LLC

  45. Expected Implementation and Operational Steps • Documentation/Superbills • Need increased documentation to support coding • Superbills need to be updated/modified • May need automated support based on increase in codes. • IT System Changes • System analysis • Programming • Testing internally • End to end testing • Partner testing Nachimson Advisors, LLC

  46. Expected Implementation and Operational Steps • Patient education • Communication with plans/trading partners • External testing • Transition Nachimson Advisors, LLC

  47. Diagnoses 5770 - Acute pancreatitis 27789 – Other specific metabolic disorders 2512 – Hypoglycemia NOS Procedures None DRG 439 Disorders of pancreas exc. malignancy w CC $6,144.60 Diagnoses K850 – Idiopathic acute pancreatitis E889 – Metabolic disorder, unspecified E162 – Hypoglycemia Procedures None DRG 440 Disorders of pancreas exc. malignancy w/o CC/MCC $4,186.20 ICD-9-CM Diagnoses K850 - Idiopathic acute pancreatitis E803 - Defects of Catalase and Perioxidase E162 - Hypoglycemia Procedures None DRG 439 Disorders of pancreas exc. malignancy w CC $6,144.60 35 Year-old Male w/ Pancreatitis (Reimbursement Risk = $1,958) ICD-10-CM/PCS

  48. Diagnoses 82003 – Closed fracture of base of neck of femur Procedures 8152 – Partial hip replacement Diagnoses S72041A - Displaced fracture of base of neck, right femur Procedures 0QR80JZ - Open femoral shaft replacement w/ synthetic substitute DRG 470 Major jnt replacement or reattachment, lower extremity, w/o MCC $12,462.00 DRG 482 Hip & femur procs exc. major joint w/o CC/MCC $8,969.40 ICD-9-CM Diagnoses S72041A - Displaced fracture of base of neck, right femur Procedures 0QR70JZ - Open upper femur replacement w/ synthetic substitute DRG 470 Major jnt replacement or reattachment, lower extremity, w/o MCC $12,462.00 82 Year-old Female Hip Replacement (Reimbursement Risk = $3,493) ICD-10-CM/PCS

  49. What Will This Cost • Training - $195 per provider/admin staff, $1625 per coder • Business Process Analysis – 3-4 months for a team to research • Changes to superbills • IT Costs – Much higher than transaction implementation • Documentation – 15% increase in time • Increases in claim inquiries, reduction in cash flow – 1% at a minimum Nachimson Advisors, LLC

  50. Expected Timing • When can this start? • What other priorities are in line? • What needs to be put aside? • Remember that HIPAA transaction upgrade will also be occurring • What 5010 changes can be done jointly with ICD-10 changes? • How long will this take? Nachimson Advisors, LLC

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