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Version 5010 electronic administrative transactions

January 1, 2012 Compliance Deadline
January 1, 2012 marks the compliance deadline for use of the new version of the standard electronic Health Insurance Portability and Accountability (HIPAA) transactions. Version 4010 had been in use since 2003 and regulations published in 2009 require all HIPAA "covered entities", which includes physicians who conduct any of the transactions named in HIPAA electronically (i.e. claims or remittance advice), to begin using Version 5010 starting on January 1, 2012.

Discretionary Grace Period Has Ended
The Centers for Medicare & Medicaid Services (CMS), the agency charge with overseeing compliance with HIPAA, had granted a discretionary grace period with its enforcement of the compliance deadline. This grace period ended on June 30, 2012. As of now, all HIPAA covered entities must be sending and receiving only the Version 5010 transactions.

Resolving Issues with Electronic Administrative Transactions
If you experience claims / cash flow interruptions with any of your payers, including Medicare, and have been unable to resolve your issues by contacting the payer directly you may file a HIPAA compliance complaint directly with CMS.

Background on Version 5010
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, you must be using the Version 5010 transactions. The move from the Version 4010 to Version 5010 transactions came through regulations issued by CMS in 2009.

See the educational resources tab below for additional information on HIPAA, Version 5010 transactions and preparing your practice for implementing the transactions.

Updating to the 5010 transactions

The version of the transactions first named under HIPAA was Version 004010 (4010) and its subsequent addenda, 004010A1 (4010A1), which are collectively referred to as "4010." The 4010 transactions were completed by Accredited Standards Committee X12 in 2000. The 4010A1 changes were completed in 2002. After that, 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 Version 4010 was named in a federal rule, the regulatory process had to be followed to upgrade to Version 5010. The Final Rule was published on January 16, 2009 and made the 5010 transactions mandatory on January 1, 2012.

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.

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 4010 of the professional claim transaction, anesthesia services may be reported in actual minutes or in units of time. In the 5010, 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.

5010 FAQs

What is "5010"?
5010 is the next adopted version of the HIPAA electronic transaction standards. "5010" is the abbreviated way to refer to Version 005010 of the Accredited Standards Committee (ASC) X12 Technical Reports Type 3 (TR3s). The TR3s are the implementation guides for the ASC X12 administrative transactions, some of which are named in HIPAA and are required to be used when conducting the transaction electronically.

Do I have to upgrade to 5010?
Yes. Providers, including physicians, are HIPAA "covered entities", which means that you must comply with the HIPAA requirements when conducting the named transactions electronically. If you currently send and receive HIPAA transactions and plan to continue doing so, then you will be required to upgrade to 5010.

Who else has to upgrade to 5010?
Health care clearinghouses and payers are also HIPAA covered entities, so they will need to upgrade to 5010 as well.

Why is the current version of the transactions being replaced?
Just like other software applications you use, the versions become outdated and need to be updated. Version 004010 ("4010") of the transactions was completed in 2000. Later changes, known as Version 004010A1 ("4010A1"), were completed in 2002. Since then, many technical issues were found in the transactions and new business needs were identified that could not be accommodated. ASC X12 developed version 5010 to correct these issues.

When do I have to upgrade to 5010?
The compliance deadline for using only the 5010 transactions is January 1, 2012. The necessary software and system changes need to be in place by the compliance date in order for you to continue sending and receiving HIPAA electronic transactions.

How does upgrading to 5010 relate to ICD-10?
ICD-10 is the upgraded version of ICD-9. The ICD-10 codes have a different format and length than the ICD-9 codes. The new format of the ICD-10 codes cannot be reported in the current version of the HIPAA transactions. So, the upgrade to 5010 needs to be completed before the ICD-10 codes can be reported in the HIPAA transactions. Learn more about ICD-10 on the ICD-10 resource page.

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