HIPAA requires the U.S. Department of Health and Human Services (HHS) to adopt required standards for covered entities to use when conducting certain health care transactions electronically, such as claims, remittance advices, and requests and responses for eligibility and claims status. Covered entities include health plans, health care clearinghouses, and health care providers.
The current transaction standard is X12 version 4010A1 for health care claims, remittance advices, eligibility, claims status, referrals, and NCPDP version 5.1 for pharmacy claims. The Centers for Medicare & Medicaid Services (CMS) has mandated that the industry upgrade to X12 version 5010 and NCPDP version D.0. The new standards will:
The implementation of HIPAA 5010 means substantial changes in the data that you submit with your claims as well as the data you receive in response to your electronic inquiries. The implementation may require changes to the software, systems, and perhaps procedures that you use for billing Medicare and other payers.
It is extremely important that you are aware of these HIPAA changes and plan for their implementation.
ICD-9 Clinical Modification (ICD-9-CM) is nearly 30 years old, and many of its diagnosis categories are full, preventing further expansion. In fact, it’s estimated that the ICD-9-CM procedure code set will run out of codes in 2009. In addition, ICD-9-CM is not flexible enough to quickly incorporate emerging diagnoses and procedures. Also, it is not accurate enough to identify diagnoses and procedures precisely. In contrast, ICD-10-CM provides detailed information on procedures, allows ample space for capturing new technology and devices, and has a logical structure with clear, consistent definitions.