X12 Version 5010 for HIPAA transactions

On January 16, 2009, United States Department of Health and Human Services published a final rule adopting X12 Version 5010 for HIPAA transactions.

The compliance dates for Version 5010 for all covered entities, is January 1, 2012.  This gives the industry time to test the standards internally to ensure that systems have been appropriately updated, and then to test with trading partners before the compliance date.

This final rule adopts updated versions of the standards for electronic transactions originally adopted under the Administrative Simplification Subtitle of the Health Insurance Portability and Accountability Act of 1996.  In addition, this final rule adopts two standards for billing retail pharmacy supplies and professional services, and clarifies who the ‘‘senders’’ and ‘‘receivers’’ are in the descriptions of certain transactions.

The improved eligibility responses will improve efficiency for providers and reduce phone calls for both providers and health plans.

The detailed clarifications of commonly misunderstood areas such as corrections and reversals, refund processing and reimbursements should result in a consistent implementation of the X12 835 Remittance Advice, which is not the case today.  Incorrect implementations of the X12 835 have prevented providers from implementing electronic posting, or automating the data entry of reimbursement information as widely as they might otherwise.  Correct implementation of the X12 835 will reduce phone calls to health plans, reduce appeals due to incomplete information, eliminate unnecessary customer support, and reduce the cost of sending and processing paper remittance advices.

The greatly improved X12 278 for Referrals and Authorizations could encourage wider implementation and save labor costs.

The new Claims transaction standard contained in Version 5010 significantly improves the reporting of clinical data, enabling the reporting of ICD–10–CM diagnosis codes and ICD–10–PCS procedure codes, and distinguishes between principal diagnosis, admitting diagnosis, external cause of injury and patient reason for visit codes.  These distinctions will improve the understanding of clinical data and enable better monitoring of mortality rates for certain illnesses, outcomes for specific treatment options, and hospital length of stay for certain conditions, as well as the clinical reasons for why the patient sought hospital care.  Another improvement in the updated claims standard is the ability to handle identification of the ‘‘Present on Admission’’ (POA) indicator to the diagnoses.

There are nearly 850 changes between Version 4010/4010A and Version 5010 to be analyzed and potentially implemented. One example is the X12 270/271 Eligibility transaction, which will require a more detailed response with less information supplied. Plans will have to determine where the data can be accessed and whether it exists within the current software; in many cases, it will not be a case of moving a few extra fields, and databases may have to be modified or created.

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Final rule for X12 5010 – http://edocket.access.gpo.gov/2009/pdf/E9-740.pdf

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