Version 5010 electronic administrative transactions
If you electronically submit administrative transactions, such as checking a patient’s eligibility, filing a claim, or receiving a remittance advice, either directly to a health insurance payer or through a clearinghouse, the version of the transactions currently in use will be updated. On January 16, 2009, the Department of Health and Human Services (HHS) announced that updated versions of the HIPAA transactions will be required for use by physicians and others on January 1, 2012. The Centers for Medicare and Medicaid Services (CMS), is the agency within HHS charged with overseeing compliance with the standards.
Updating to the 5010 transactions
The version of the transactions named in HIPAA is Version 004010 (4010) and its subsequent addenda, 004010A1 (4010A1), are collectively referred to as “4010A1.” The 4010 transactions were completed by Accredited Standards Committee X12 in 2000. The 4010A1 changes were completed in 2002. Since then, many technical issues identified in the transactions were corrected and changes were made to accommodate new business needs. ASC X12 continuously works on updating its standards and implementation guides for the transactions to better meet the needs of the health care industry. Work was completed between 2006 and 2007 on a newer version of each transaction, Version 005010, commonly called “5010.”
Because the 4010A1 version of the transactions is named in a federal rule, the regulatory process must be followed to upgrade to the 5010 version. In 2007, a request was made to the Secretary of HHS to modify HIPAA to replace version 4010A1 with version 5010. The Final Rule was published on January 16, 2009 and makes the 5010 transactions mandatory on January 1, 2012. The Final Rule allows for the use of the 5010 transactions prior to the compliance date to facilitate the migration to the updated transactions and prevent the need to convert overnight.
In addition, a Final Rule adopting ICD-10 as the new code set to replace ICD-9 –CM, Volumes 1 & 2 – something that cannot occur prior to moving to use of the 5010 transactions – has been issued. The use of the ICD-10 code set will be mandatory as of October 1, 2013. Because of the need to convert to ICD-10 so soon after complying with 5010, it is imperative that practices begin their transition work to 5010 as early as possible. The Final Rule does not allows for the use of ICD-10 codes prior to the compliance date.
Changes in the 5010 transactions
Improvements in the 5010 transactions include clearer instructions, reduced ambiguity among common data elements used in different transactions, and elimination of redundant and unnecessary data elements.
The updated version of the transactions has data reporting requirements that differ somewhat from the current transactions. These changes may require you to collect additional data or report data in a different format. For example, in the 4010A1 version of the professional claim transaction, anesthesia services may be reported in actual minutes or in units of time. In the 5010 version, only actual minutes may be reported. Another example of a difference in the professional claim transaction is the reporting of the billing provider address. In 5010, the address can no longer be a PO Box or lockbox address.
Understanding these changes and how they will affect your practice will prepare you for a smoother transition to the updated transactions.
What practices can do now to prepare for 5010
The biggest concern for practices will be complete implementation and full functionality of the 5010 transactions at or before the compliance deadline to avoid transaction rejections and subsequent payment delays. Practices can begin now to prepare for this upcoming effort by developing their own implementation plan. The following are various tasks to include in an implementation plan.
- Talk to your current practice management system vendor.
- Talk to your clearinghouses or billing service, if you use either one, and health insurance payers.
- Identify changes to data reporting requirements.
- Identify potential changes to existing practice work flow and business processes.
- Identify staff training needs.
- Test with your trading partners, e.g., payers and clearinghouses.
- Budget for implementation costs, including expenses for system changes, resource materials, consultants, and training.
The following are additional resources for you to use when implementing the 5010 transactions:
AMA Advocacy
AMA Comment Letter on the 5010 Proposed Rule
AMA Educational Resources
7 Steps Practices Can Take Now to Prepare for 5010
Additional resources:
The following links will take you off the AMA Web site. The AMA is not responsible for the content of other Web sites.
