As the deadlines for transitioning to HIPAA 5010 and ICD-10 rapidly approach, all practices are beginning to wonder what they should be doing to prepare for the changes. To help prepare practices for the transitions, we will be answering some of the most common questions about 5010 and ICD-10 in the coming months.

• How do we update to 5010? Depending on your practice’s stance, everyone will make this transition differently. A lot of this also depends on how you submit claims. For example, many clearinghouses are working to implement processes that will automatically convert data into the proper format. With that being said, every practice should check with their healthcare technology (HIT) vendors to find out what steps they will be required to take and how the transitions will impact them. If you don’t have a clearinghouse, you will have to test with every one of your direct payers.
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The transition to Version 5010 may require your practice to make many changes in the way you submit claims, but the following four requirements are especially important to acknowledge and start thinking about now. Giving consideration to these changes and beginning communications with payers about them is something you can do right now to help lay the groundwork for a successful 5010 transition.

Change 1: Consistently enrolling National Provider Identifier (NPI) subparts. If your practice has multiple NPI subparts, you need to make sure you’ve enrolled them consistently with all payers using the lowest level enumeration. In addition, for payers that do crosswalk lookups, you should verify that the claim’s practice name and address matches what the crosswalk contains. These two efforts can help avoid enrollment problems and realize consistent reporting.

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With 5010 and ICD-10 looming on the horizon, now is the time for practices to begin safeguarding against spikes in rejections and denials. Rejections and denials are, obviously, important barometers of financial health that must be tracked at all times. But accurate tracking becomes even more important during times of change.

In my opinion, practices should begin considering periods of transition as “the new normal.” After all, fresh legislative mandates seem to be hitting the healthcare industry with increasing regularity. It might be wise to invest a little time in developing policies and processes to monitor key practice indicators during times of upheaval.

Rejections and denials offer the perfect place to start. Right now is a good time to begin establishing benchmarks for these numbers in your practice. Don’t wait until December 31 to determine your average rejection and denial levels—do this in the months prior to the 5010 conversion on January 1, 2012. That way, you have an accurate yardstick against which to measure your post-conversion rejections and denials.

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Practices are well aware of the pending changes stemming from the transition to the new ICD-10 coding set that will occur on October 1, 2013, and many already are in the midst of making sure that they are fully prepared for this shift. Some steps that practices are taking right now include: developing committees to assess what software and IT upgrades need to be made; finalizing internal staff training plans; and creating implementation plans to ensure readiness by all staff.

Although these steps are exactly what practices should be doing to prepare for ICD-10, many people are still wondering if the compliance deadline will be extended—and what penalties they will face if their practices are not prepared when that deadline rolls around.

First, I am confident in saying that ICD-10 has a hard cut-over date of October 1, 2013. The Centers for Medicare and Medicaid Services (CMS) feels like it already has granted practices a two-year “extension” of sorts by pushing back its originally proposed 2011 implementation date.

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By now everyone in the healthcare industry has heard about the Version 5010 transition that will take place on Jan. 1, 2012. However, I am sure some people may still wonder exactly what this transition is—and how healthcare practices will benefit from the transition.

To understand how 5010 will help your practice, just imagine traveling to a country where everyone speaks a different dialect of the same language. In this environment, you are trying to conduct very important business transactions, where crucial details and nuances might be misinterpreted.

That is exactly the predicament the healthcare industry has faced for years. Now, however, Version 5010 of the electronic transaction standards promises to become a universal dictionary that will allow everyone to speak the same language, in the same dialect— essentially enabling apples-to-apples “conversations” among all healthcare entities. And that, in turn, will help every practice reap the benefits of improved claims filing, payment posting, eligibility verification, and other vital revenue cycle management (RCM) functions.

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The question came to me the other day: How does a clearinghouse fit into the broader scope of healthcare reform initiatives designed to reward quality care improvement? I think the answer has to do with practice productivity. While there are a number of ways to go about participating in incentive-based reform initiatives, practice productivity will be a key element in their success.

Think of all the things you must do at work every day. Everything takes time. So, let’s say your practice has decided to participate in the Physician Quality Reporting Initiative (PQRI). That single decision requires you to: read and understand the regulations; choose which PQRI measures your providers will track; and determine the most efficient methods for reporting, tracking, and getting reimbursed for those measures. It’s not something you can do in 20 minutes. Read More ›

By now, every healthcare facility in the country should be aware that two major conversions are imminent. The transition to the 5010 electronic transaction standards must take place by January 1, 2012 and is the first required step in the transition to ICD-10. The transition to the ICD-10-CM (diagnosis) and ICD-10-PCS (hospital procedure) code sets must take place by October 1, 2013.

With the 5010 conversion looming more immediately on the horizon, attention understandably has been diverted away from ICD-10. Even in times of stretched resources, however, it’s important to try to tackle these transitions as concurrently as possible.

Fortunately, the bulk of the 5010 transition will be the responsibility of healthcare IT vendors such as clearinghouse, EHR, practice management, and other software product providers. It will be largely up to these vendors to make sure their products comply with the new data standards. However, it is up to physician practices to verify that their vendors are ready for the transition. Otherwise, practices risk claims rejections by insurance companies—and resulting cash flow interruptions. Read More ›

As is fairly typical, industry focus on Version 5010 of the electronic transaction standards has waned a bit as new rules and regulations steal the spotlight. But I’d like to urge you not to let your 5010 transition plans get waylaid by other priorities—January 1, 2012 is only slightly more than 14 months away. That’s not much time for a conversion of such far-reaching magnitude.

By this time, you should have a pretty thorough understanding of exactly what the 5010 transition will mean to your practice’s daily operations. But avoiding cash flow interruptions during—and immediately after—the transition to 5010 should remain a paramount concern. I recommend that practices take the following steps to minimize potential disruption: Read More ›

A seamless transition. That’s the goal we all seek in the colossal dual conversion of our HIPAA 4010 X12 files to the new 5010 standard, and the ICD-9 to ICD-10 code sets. Somehow, with a tight timeline and crunched budgets, we must simultaneously pull off two technically challenging migrations – and do it all with minimal disruption to business operations. The task, at times, feels overwhelming.

As you research your options, however, I’d suggest that one important place to begin is with a candid assessment of your organizational partnerships. The Herculean effort needed to successfully transition these two critical data sets at the same time will require close collaboration with trustworthy and responsive partners, each working within a well-defined area of expertise. Read More ›

In this age of automation, it’s tempting to rely on technology solutions alone to ease the burden of coding operations. And that’s OK; making coding easier is the primary purpose behind many of the coding and documentation tools available from leading EMR applications.

However, I’d like to offer a caveat: please don’t allow confidence in technology to detract from the value of self-audits. Technological aids don’t render coding and billing audits obsolete. As advantageous as some coding tools are, ongoing self-evaluation remains the single best way to ensure optimal coding practices – those that garner appropriate reimbursement while also protecting against payer investigations. Read More ›