Transaction and Code Set Standards
On January 16, 2009, the Department of Health and Human Services (HHS) announced that an updated version of the HIPAA standards will be required for use starting on January 1, 2012. The updated version of these standards are referred to as 5010. Also announced by HHS was the requirement to move from use of ICD-9 to ICD-10.
Background
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) included a section on administrative simplification and mandated the adoption of regulations for privacy, security, unique health identifiers, and electronic transactions and code sets. The Transactions and Code Sets Final Rule was issued in 2000 by HHS and named standard transactions to be used by “covered entities,” defined as health care providers (including physicians), payers, and clearinghouses, when conducting specific administrative transactions electronically. Physicians are not required by HIPAA to do any of the below listed transactions electronically. Rather, HIPAA requires any physician who chooses to do these transactions electronically to comply with the HIPAA standards.
Listed below are the administrative transactions that were named. In the industry these transactions are commonly referred to by a certain number which is included next to each one in parenthesis:
- Health claims or equivalent encounter information (837)
- Enrollment and disenrollment in a health plan (834)
- Eligibility for a health plan (270/271)
- Health care payment and remittance advice (835)
- Health plan premium payments (820)
- Health claim status (276/277)
- Referral certification and authorization (278)
The version of the transactions named in HIPAA is Version 004010 (4010) and its subsequent addenda, 004010A1 (4010A1), are collectively referred to as “4010A1.” These electronic transactions were developed by the standards development organization Accredited Standards Committee X12 (ASC X12). Standards development organizations are bodies that develop standards used in various industries, such as banking standards that enable you to use your ATM card in any ATM.
The Transactions and Code Sets Final Rule included standards for pharmacy transactions, which are not addressed here.
As of October 16, 2003 all physicians and others who conduct the above administrative transactions electronically, were required to use the 4010A1 transactions. However, as mentioned above, HHS is requiring those physicians and others covered under the law, who conduct any of the aforementioned transactions electronically, to begin using the updated standard known as 5010.
Submission of electronic Medicare claims
Although HIPAA does not require physicians to use electronic transactions, a related law, the Administrative Simplification Compliance Act (ASCA), does impose such a requirement for physicians who bill Medicare. ASCA requires that all claims submitted to the Medicare program must be submitted in electronic form, with some limited exceptions. The implication of this requirement is that because the claims are submitted electronically, they are also required to comply with HIPAA. The compliance date for the requirement to submit Medicare claims electronically was October 16, 2003. Physicians who are considered “small providers” defined as those having fewer than 10 full-time equivalent employees in their practice may continue sending paper claims. The law provides for a few other limited exceptions. More information on these can be found on the CMS Web site.
Additional information on HIPAA transactions and code sets:
Understanding the HIPAA standard transactions: The HIPAA Transactions and Code Set rule (PDF)
Information Technology solutions: Consider the potential savings (PDF)
The benefits of electronic claims submission – improve practice efficiencies (PDF)
HIPAA Transaction Code Set Vendor survey (PDF)
What is a Clearinghouse? (PDF)
What is a Medical Billing Service? (PDF)
How to Select a Billing Software Vendor for the Physician Practice (PDF)
