In January 2010, the U.S. Department of Health and Human Services (HHS) released two final rules regarding the adoption of a new generation of diagnosis and procedure codes (ICD-10 code sets), and updated standards for electronic healthcare (version 5010), pharmacy transactions (version D.0), and Medicaid pharmacy subrogation transactions (version 3.0).

Who is Affected by the Transition to Version 5010 and D.0?

HIPAA covered entities affected by the transition to Versions 5010 (some healthcare transactions), D.0 (pharmacy transactions), and Medicaid pharmacy subrogation transactions (version 3.0) include the following:

  • Providers such as physicians, alternate site providers, rehab clinics, and hospitals
  • Health Plans
  • Healthcare Clearing Houses
  • Business Associates that use the affected transactions like billing or service agents, provider organizations and vendors

What files will be affected by 5010?

Version 5010 includes updated standards for claims, remittance advice, eligibility inquiries, referral authorization, and other administrative transactions.

Compliance Dates:

       •  Adoption of ICD-10 Code Sets
              ›  Compliance date of October 1, 2013
       •  5010 and D.0
              ›  Mandatory compliance on January 1, 2012 (all covered entities)
              ›  Level 1 target should be completed by December 31, 2010
                     (Level 1 target means the completion of internal testing to determine
                     if the covered entity can receive or transmit the HIPAA-compliant
              ›  Level 2 target should be completed by December 31, 2011
                     (Level 2 target means beginning to end testing is completed - example: 
                     successfully sending a HIPAA compliant file from the provider through a
                     clearing house to an insurance company)
              ›  Cut off date for receiving old transactions is January 1, 2012
       •  Version 3.0
              ›  Mandatory compliance on January 1, 2012 (all covered entities)
              ›  Small health plans have an additional year and must comply on
                 January 1, 2013
What does this mean for a physician's office?
  • The majority of the effort to change over to the 5010 and D.0 systems will fall on the vendors practices use (programming changes to software)
  • Providers are responsible for identifying their systems that need upgrades
  • Practices will need to get software upgrades installed and tested
  • Staff will need to be trained on the new fuctionalities of the software
  • Failure to make the changes in a timely manner may lead to penalties and claims not getting paid
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