5010 Standards
and ICD-10

A new version of the
HIPAA standard transactions



Secure EDI is making these changes and
wanted to update you on our progress



November 21, 2011: Secure EDI adopts HIPAA standard transactions

In compliance with the U.S. Department of Health and Human Services final rule under the Health Insurance Portability and Accountability Act Secure EDI announces production X12 5010 ANSI transactions to include claims, remittances, and functional acknowledgements (837, 835, 999, 277CA). The remaining transactions will be placed into production by mutual agreement with trading partners prior to January 1, 2012.


On January 16, 2009, The Department of Health and Human Services (DHHS) published two final rules to adopt updated HIPAA standards.

In one rule, HHS is adopting X12 Version 5010 and NCPDP Version D.0 for HIPAA transactions. In this rule, HHS also adopts a new standard for Medicaid subrogation for pharmacy claims, known as NCPDP Version 3.0. For Version 5010 and Version D.0, the compliance date for all covered entities is January 1, 2012.

If you have general questions, comments, or for all detailed questions about files, companion guides, and gap analyses please contact e-mail our 5010 transition team at: hipaa5010@secureedi.com

Read complete overview
This gives the industry enough time to test the standards internally, to ensure that systems have been appropriately updated, and then to test between trading partners before the compliance date. The compliance date for the Medicaid subrogation standard is also January 1, 2012, except for small health plans, which will have until January 1, 2013 to come into compliance.

In a separate final rule, HHS modifies the standard medical data code sets for coding diagnoses and inpatient hospital procedures by concurrently adopting the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) for diagnosis coding and the International Classification of Diseases, 10th Revision, Procedural Coding System (ICD-10-PCS) for inpatient hospital procedure coding. These new codes replace the current International Classification, 9th Revision, Clinical Modification, Volumes 1 and 2 and the International Classification, 9th Revision, Clinical Modification, Volume 3 for diagnosis and procedure codes respectively. The implementation date for ICD-10-CM and ICD-10-PCS is October 1, 2013 for all covered entities.

Version 5010 accommodates the ICD-10 code sets, and has an earlier compliance date than ICD-10 in order to ensure adequate testing time for the industry. These two rules apply to all HIPAA covered entities, including health plans, health care clearinghouses, and certain health care providers.

Secure EDI committed to help many of our trading partners with conversion between versions. Consequently, we expect to support both versions for the foreseeable future.


Compliance timeline

Federal Date Compliance Step
January 1, 2010 Payers and providers should begin internal testing of Version 5010 standards for electronic claims
December 31, 2010 Internal testing of Version 5010 must be complete to achieve Level I Version 5010 compliance
January 1, 2011 • Payers and providers should begin external testing of Version 5010 for electronic claims
• CMS begins accepting Version 5010 claims
• Version 4010 claims continue to be accepted
December 31, 2011 External testing of Version 5010 for electronic claims must be complete to achieve Level II Version 5010 compliance
January 1, 2012 • All electronic claims must use Version 5010
• Version 4010 claims are no longer accepted
October 1, 2013 • Claims for services provided on or after this date must use ICD-10 codes for medical diagnosis and inpatient procedures
• CPT codes will continue to be used for outpatient services

Basic Steps for Providers to Prepare for Version 5010/ICD-10

Begin preparing now for the ICD-10 transition to make sure you are ready by the October 1, 2013, compliance deadline. The following quick checklist will assist you with preliminary planning steps.
Read complete overview
  • • Identify your current systems and work processes that use ICD-9 codes.
  • • Talk with your practice management system vendor about accommodations for both Version 5010 and ICD-10 codes.
  • • Discuss implementation plans with all your clearinghouses, billing services, and payers to ensure a smooth transition.
  • • Talk with your payers about how ICD-10 implementation might affect your contracts.
  • • Identify potential changes to work flow and business processes.
  • • Assess staff training needs.
  • • Budget for time and costs related to ICD-10 implementation, including expenses for system changes, resource materials, and training.
  • • Conduct test transactions using Version 5010/ICD-10 codes with your payers and clearinghouses.

HIPAA 5010 Transactions affected

Transactions X12 Standard TR3
Enrollment 834 X220
Premium Payment 820 X218
Eligibility & Benefits Inquiry & Response 270 & 271 X279
Authorization 278 X217
Claims – Professional 837 X222
Claims – Institutional 837 X223
Claims – Dental 837 X224
Claim Status Inquiry & Response 276 & 277 X212
Remittance 835 X221

Differences between ICD-9/ICD10

There are several changes in the ICD-10. Because of the close relation of ICD-CM to the original ICD, it is important to note that these changes will become part of the ICD-10-CM. Some of the most important changes are:
  1. ICD-10 is much bigger with almost twice the categories of ICD-9.
  2. ICD-10 uses alphanumeric categories instead of numeric only.
  3. ICD-10 changed chapters, categories, titles and regrouped conditions.

Secure EDI Companion Guides

FAQ

What is version 5010 of the x12 HIPAA transaction and code set standards?

Currently, the transaction standard in use is the X12 version 4010A1. The 4010 transaction standards drive billing, reimbursement, and administrative functions. CMS is requiring the industry to upgrade from the 4010 transaction standard to 5010. Therefore, HIPAA X12 version 5010 is the new set of standards that regulate the electronic transmission of specific health care transactions including eligibility, claim status, referrals, claims, and remittances.

Is the 5010 conversion a mandatory change?

Yes. Use of the 5010 version of the X12 standard is required by federal law. The deadline to comply with HIPAA 5010 standards is January 1, 2012.

Who will need to upgrade to HIPAA 5010?

All covered entities (includes health plans, health care clearinghouses, and health care providers) are required to upgrade to HIPAA 5010 standards; covered entities may use a clearinghouse to assist them with complying with the rules. While software vendors are not included in the list of covered entities, they will also need to upgrade their products in order to support their customers.

What are the benefits of the 5010 standards?

The 5010 standards promise many improvements to EDI transactions including greater clarity in provider loops and NPI instructions, reduced ambiguity among common data elements, and elimination of unnecessary or redundant data elements. It also provides support for the five-fold increase (from approximately 16,000 to over 65,000 codes) in the new ICD-10 code set. Switching to the HIPAA 5010 transaction sets for claims and related transaction will improve transaction uniformity, support pay-for-performance programs, and streamline reimbursement transactions.

What transactions are specified in the HIPAA 5010 standards?


270/271 – Health Care Eligibility Benefit Inquiry and Response
276/277 – Health Care Claim Status Request and Response
278 – Health Care Services – Request for Review and Response; Health Care Services Notification and Acknowledgment
835 – Health Care Claim Payment/Advice
837 – Health Care Claim (Professional, Institutional, and Dental), including coordination of benefits (COB) and subrogation claim

When did Secure EDI begin processing 5010 transactions in production?

October 26, 2011

Are the technical reports (implementation guides) available to the public?

The Technical Reports (TR3 Documents) and their addenda can be purchased from the Washington Publishing Company: http://www.wpc-edi.com/ These TR3 documents include:
X222 – Health Care Claim: Professional (837)
X223 – Health Care Claim: Institutional (837)
X224 – Health Care Claim: Dental (837)
X221 – Health Care Claims Payment/Advice (835)
X279 – Health Care Eligibility Benefit Inquiry and Response (270/271)
X217 – Health Care Services Review - Request for Review and Response (278)

What are the major differences between HIPAA 4010A1 and HIPAA 5010?

Version 5010 provides some advantages over the previous version: Version 5010 accommodates ICD-10 values; 4010A1 does not accommodate ICD-10 codes. The 5010 guides clarify how the transactions should be formatted It adds new business functionality when appropriate and removes other functionality that is obsolete.

For example:
1. The NPI is required for all health care provider types. Tax IDs or Social Security numbers are no longer accepted.
2. The provider taxonomy code has been changed from ZZ to PXC.
3. Extraneous codes in several segments are no longer permitted.
4. Situational requirements have been made more specific.

Will Secure EDI be accepting HIPAA 4010A transactions after January 12, 2012?

We expect to help many of our trading partners with conversion between versions. Consequently, we expect to support both versions for the foreseeable future.

Will Secure EDI offer the 999 Acknowledgement?

Secure EDI will be adopting the new industry standard acknowledgement, the 999 transactions. Secure EDI will discontinue the use of the 997 when HIPAA 5010 is implemented.

Why is it necessary to upgrade to HIPAA 5010?

Federal law requires the upgrade to HIPAA 5010. In January 2009, The U.S. Department of Health and Human Services (HHS) announced a rule that mandates updated standards for electronic health care and pharmacy transactions. The upgrade to 5010 is important because the new version will be able to accommodate the forthcoming and mandatory ICD-10-CM and ICD-10-PCS code sets, which are scheduled to be implemented on October 1, 2013.

How can covered entities prepare for the transition to HIPAA 5010?

Your organization can prepare by reviewing the Technical Reports Type 3 (or TR3s), with your business partners, such as clearinghouses and software vendors. TR3 Guides can be purchased through Washington Publishing.

ICD-10 5010 Hipaa Standard