Monday, August 16, 2010

HIPAA 5010 Checkup: Ten Things to Consider

We are just four months away from CMS' Level 1 compliance date for implementation of the updated X12N transactions to version 5010 for HIPAA.  You've come to see the 5010 doctor.  Run your implementation through my "5010 Checkup" below to see how you're doing:

  1. Perform a Gap Analysis between 4010 and 5010 to determine the changes for your organization.  CMS has provided an easy-to-read side-by-side comparison of the differences between 4010 and 5010.  This will identify the detailed list of changes needed for your 5010 implementation.
  2. Decide what is in scope for your 5010 project versus ICD-10 project.  The changes in 5010 support the increase in field length to support ICD-10.  How much ICD-10 related tasks do you want to include in your 5010 implementation?  What happens if a Physician sends an ICD-10 code to a Payer before the ICD-10 mandate date of October 2013?
  3. Decide the transaction to use for sending/receiving acknowledgements in 997 versus 999.  WEDI has a recommendation that says 999 is a must to acknowledge 5010 transactions and not the 997.  I recommend that everyone follow suit and adopt the 999.
  4. Consider the impacts on vendors and internal processes.  Some external and internal systems have a solution architecture that employs the X12N transactions as an interface between systems.  Such as payers that have a partnership where they use the 4010 834 to exchange respective member information or an internal system that turns a paper claim into a 4010 837.  Though these are not mandated to transact in 5010, make a list of what these interfaces are and make a decision if it will remain on 4010 or be upgraded to 5010.  This will make sure you have covered all the bases.
  5. Give 837 the highest priority as the first one out the gate.  By far the largest amount of coordination and testing in the industry will involve the 5010 837I and 837P.  Given that some entities still have much to do, I suggest getting the 837 out there first so Providers, Clearinghouses and Payers can start testing sooner.  ICD10Watch poll finds that 60 percent of health org's uncertain about meeting HIPAA 5010 Level 1 deadline.
  6. Coordinate with your covered entities to determine when to Test.  Make a list of all the Providers, Clearinghouses, Vendors and Payers in which you transact HIPAA transactions and reach out to determine their readiness for 5010 and when you can start testing with them.
  7. For Physician offices, contact your software vendors and determine their readiness for 5010.  Your software vendor is probably deep in getting the software ready for 5010.  Just make sure you confirm that this is the case.
  8. Determine how you will read the 277CA.  The 277CA is the claims acknowledgement where you can find out claim numbers and any errors coming from the Payer for claims that you submitted.  The 277CA isn't new, however, CMS Fee-for-Service will be using it for the first time, eliminating their human readable reports.  Make sure you have a means to read this; the solution will probably come through the software solution from your software vendor.
  9. Determine if you will support Employer Groups to stay on 834 version 4010 and 820 version 4010.  Or will you support 4010 and 5010 for the 834 and 820?  By the way, Health Care Reform in 2016 will necessitate changes again to these transactions...  Employer Groups are not covered entities and therefore, (though I am not a lawyer) I believe they can choose to stay on 4010.
  10. Review X12N Errata's.  In the last two weeks, the X12N transactions have been modified via Errata's.  Most are minor changes, with the biggest one impacting the 835, where it now must send back the Patient Name corresponding to what was sent on the 837.  In the past, Payers may have been sending the Patient Name on record from their Membership application, so this may be a good size change for some. 
CMS also has provided two checklists worth reviewing: Checklist for Level I Testing Activities and Provider Action Checklist for a Smooth Transition.

Remember that the intent of the updates made in X12N version 5010 is to make the transactions better based on what we've collectively learned since we started using 4010 a couple years ago.  Therefore, a majority of the changes are layout and consistency across transactions and the complexity of this implementation isn't as high as when we instituted 4010.  I think this 5010 implementation can be pretty straightforward; the simple secret to success is to be a Task Master and make a list of the tasks that must be completed and track them to make sure they are done.

7 comments:

Renee Lin said...

Okay, I thought of another important one:

11. Consider if you will need to employ a conversion process to translate between 4010 and 5010. For example, if you are an entity that takes what was received and sends it back out the door, you may have to be the mediator between two entities that are instituting 5010 in different points in time in the year 2011. Clearinghouses, for example, will need to do this to connect a 4010 Physician to a 5010 Payer.

Simone said...
This comment has been removed by a blog administrator.
Gox Rasil said...

Hi Renee, I would like to know what kind of testing statergies can be used for this 5010 and ICD 10 converstion ...

Renee Lin said...

Gowtham,

It will depend on your implementation. If it's a complete re-write, you will want to do more testing than if it was a change on top of the existing 4010 code. Testing, both, at a high-level for business scenarios such as Anesthesia Claims, COB Claims, PO Box Claims, etc, as well as detailed-level element-by-element changes with 5010 is recommended. Also, regression testing and your in/out gateway testing is also important. If you or your organization is a member of WEDI, they have a subworkgroup devoted to this topic. You can see their website at: http://www.wedi.org/snip/public/articles/index~30.shtml

Last suggestion is to prioritize test cases from business critical to those that are not so critical in case you run into a time crunch at the end you can still be in production with your best 5010 code.

Thanks for writing and good luck,
Renee

Angela – Vee Technologies said...

Great read!  This fantastic article clearly identifies and outlines the realities of the upcoming EDI / ICD-10 / HIPAA 4010 to 5010 conversion challenges. I work with a U.S. based strategic services company (headquartered in NY and with operations in India).  At the moment we are working with over 20 payer/provider companies, most of which we have already successfully converted them to 5010.  Even with our 10+ years of experience in the healthcare back office space, I’ve seen that with each conversion that new lessons are learned by our team on client specific peculiarities…and our process is now well matured. However, as time is growing short we are starting to see more and more companies literally rushing now to ensure that they are ready to start submitting their claims electronically using the X12 Version 5010 and NCPDP Version D.0 standards by the January 1st 2012 deadline.  We’ll keep checking back to see if you have any updates and suggestions for the industry.  Cheers, Angela Carson, Head of Communication at Vee Technologies 

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