Medicare Compliance & Reimbursement

The feds want you to clear one big hurdle before you can even consider submitting ICD-10 codes: You'll need toget used to the HIPAA 5010 form before Jan. 1, 2012.

During a June 9 Centers for Medicare & Medicaid Services Open Door Forum, agency officials outlined the important features of the new HIPAA 5010 form. Version 5010 is an improvement over the current 4010 form "because it brings many things to the table, including structural and content-oriented changes," noted Kyle Miller, health insurance specialist from CMS's office of ehealth standards and services. "In addition, version 5010 will address shortcomings from version 4010."

You'll have to start using version 5010 on Jan. 1, 2012, but CMS expects Medicare contractors to begin transitioning to the 5010 form in 2011. That way, you should be able to start submitting early to ensure that your billing software systems and contractor's claims submission service work appropriately with the new form before the requirement deadline of 2012.

"All HIPAA-covered entities are affected by the new 5010 form, including providers, health plans, and clearinghouses," said Chris Stahlecker, director of the division of Medicare billing procedures with CMS's office of information services. "In addition, any billing service agents will also be affected by the new form," she added.

"The formats that you're currently using to bill Medicare or to perform Medicare eligibility inquiries must be changed from the 4010A1 format to the 5010," Stahlecker said. You'll need to identify software and business process changes ahead of time to recognize the new form's data element changes.

Plus: CMS is "currently working on developing a new 5010 Web page that will distinctly differentiate between information for Medicare fee-for-service providers and the health care industry at large," said Aryeh Langer of CMS's provider communications group.

Check out these highlights from CMS's presentation:

• Contact your system vendors "right away" to get assurance that your licensing agreement includes regulatory updates, CMS recommends. Ask if the upgrade will include the 5010 versions of the new transactions, and if so, find out when the vendor plans to upgrade your system to ensure that it's before the deadline of Jan. 1, 2012.

• The 5010 form is making way for the ICD-10 code set. CMS describes the transition to ICD-10 as a "Y2Klike expansion of the claim record," Stahlecker said.

• The HIPAA 5010 form will increase diagnosis code field size from 5 bytes to 7 bytes, allowing for ease of use when the ICD-10 transition occurs. It also increases the number of diagnosis codes allowed on a claim. The 5010 form will allow ICD-9 and/or ICD-10 code values -- it won't solely accept ICD-10 codes, Stahlecker noted.

• The 5010 form will improve the claims receipt, control,and balancing procedures. "Our objective is that although we have multiple MACs with individual systems,we want each one to perform as if it were a virtual single system," Stahlecker explained. "You, the provider,no matter which MAC you are exchanging transactions with, should experience very similar results."

• Each MAC will be required to exercise a "certification test package" before CMS will permit that MAC to begin transitioning to the 5010 form.

Too confusing? If the new electronic billing changes required for the new 5010 form make your head spin, don't be tempted to rely on paper forms. CMS is trying to limit how many paper forms it receives and requires a waiver for providers who need to continue billing on paper. "Medicare FFS is very interested in moving toward electronic data interchange," Stahlecker said.