If you have completed the HIPAA 5010 Readiness Survey, then you are already intimately familiar with the 5010, ICD-10, D.0 lingo.

If this is the first you are hearing of this, then read on!

5010: The latest, greatest electronic transaction set that will replace the 4010A1 transaction set, beginning January 1, 2012. This will affect 837P, 837I, 270/271 and 835 transactions in CPR+.

The new version of the HIPAA standards - Version 5010 - includes structural, front matter, technical, and data content improvements. Because the updated version is more specific in requiring the data that is needed, collected, and transmitted in a transaction, its adoption will reduce ambiguities. Version 5010 also addresses a variety of currently unmet business needs, including, for example, providing removal of the Prior Authorization or Referral Number segment and creating segments for each respectively. Version 5010 also accommodates the use of the ICD-10 code sets, which are not supported by Version 4010/4010A1.

ICD-10: These procedure codes will replace the current ICD-9 codes.

Adoption of the ICD-10 code sets is expected to:

• Support value-based purchasing and Medicare’s anti-fraud and abuse activities by accurately defining services and providing specific diagnosis and treatment information;
• Support comprehensive reporting of quality data;
• Ensure more accurate payments for new procedures, fewer rejected claims, improved disease management, and harmonization of disease monitoring and reporting worldwide; and
• Allow the United States to compare its data with international data to track the incidence and spread of disease and treatment outcomes because the United States is one of the few developed countries not using ICD-10.

To view a Quick Reference Guide on the differences between ICD-9 and ICD-10, click here.

D.0: Replaces the current NCPDP version 5.1.

Version D.0 specifically addresses business needs that have evolved with the implementation of the Medicare prescription drug benefit (Part D) as well as changes within the health care industry. New data elements and rejection codes in Version D.0 will facilitate both coordination of benefits claims processing and Medicare Part D claims processing.

In addition, Version D.0:

• Provides more complete eligibility information for Medicare Part D and other insurance coverage;
• Better identifies patient responsibility, benefits stages, and coverage gaps on secondary claims; and
• Facilitates the billing of multiple ingredients in processing claims for compounded drugs.
  

The electronic claim formats should not require many changes in CPR+, but the ICD-10 changes will require a substantial effort. The ICD-10 codes present quite a challenge because there is not a one-to-one replacement for many of the existing ICD-9 codes.

I hope that this article provides a basic understanding of the 5010 transaction set, the ICD-10 procedure codes and NCPDP version D.0. In the weeks and months ahead, watch the Announcements section of the Weekly Infusion for more information on this topic. We'll do our best to keep you informed of the specific changes that we'll be making to future versions of CPR+ in order to comply with the new standards.

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