Ophthalmology and Optometry Coding Alert

The 2012 implementation deadline won't change, so now's the time to start preparing.

Making the transition to ICD-10 isn't the only industry initiative your ophthalmology practice should be learning about these days. January 1, 2012 marks the deadline for compliance with the new HIPAA Version 5010. Industry experts say the change will be time consuming, costly, and complicated -- which is why you need to take steps now toward successful migrations.

Get to Know Version 5010

The start of your transition to ICD-10 (which will be effective October 1, 2013) actually begins with a piece of health insurance reform legislation known as Version 5010. 5010 lays out the technical electronic transaction standards mandated by the Health Insurance Portability & Accountability Act of 1996 (HIPAA) transactions, and includes, among other things, requirements for transmission of claims and payment data using ICD-10.

Background: Congress enacted HIPAA to establish national standards for healthcare transactions, including (but not limited to) patient privacy, simplified insurance administration, and insurance portability. The current version (4010/4010A1) does not accommodate the ICD- 10 code set. Therefore, in preparation  for the use of ICD- 10, CMS has introduced its new HIPAA 5010 Version D.0 form, which will be required for use by all HIPAA-covered entities (i.e., providers, health plans, clearinghouses, and their business associates, including billing agents) as of Jan. 1, 2012. This implantation deadline falls long before the ICD-10 implementation date to allow adequate 5010 testing and implementation time.

In simplest terms: "Physicians submit electronic claims to Medicare using version 4010/4010A1," explains Catherine Brink, CMM, CPC, CMSCS, owner of HealthCare Resource Management, Inc., in Spring Lake, N.J. "This system format lacks functionality for certain transactions. The biggest one is ICD-10. So, version 5010/D.0 has to replace the current electronic system for submitting claims." Version 5010 will replace 4010/4010A1 for electronic transactions, including claims, eligibility inquiries, and remittance advices.

Pitfall: "We're seeing way too many billers and providers that aren't taking this deadline seriously," warns Cyndee Weston, executive director of the American Medical Billing Association in Sulpher, Okla. "They assume their software vendors and clearinghouses will ensure their claims are submitted appropriately by the deadline. We encourage all billers and providers to get involved now before they realize they have issues in getting paid."

If you're not ready to submit the 5010 form by Jan. 1, 2012, you will no longer be able to submit electronic  transactions to Medicare and you'll quickly lose money. If you practice is submitting paper claim forms now, you should not experience a change in that paper claim form for 5010 or the ICD-10 projects.

Capitalize on Diagnosis Reporting Improvements

Version 5010 will address several problems and complexities you've suffered through with 4010:

• The maximum number of diagnosis codes you can report on a claim increases from eight to 12. However, even though you can report 12 codes on the claim, you'll only be able to point or link a service to four of those diagnoses. Remember that individual payers may limit how many diagnosis codes they process.

• The 5010 format does not require the use of ICD-10 codes, but it will be able to distinguish between the ICD-9 and ICD-10 code sets. The 5010 transaction set increases the field size for ICD codes from 5 to 7 and also adds a version indicator to the ICD code to indicate version 9 versus 10.

• 5010 allows you to submit either ICD-10 or ICD-9 on the claim but not both on the same claim.

• The new form "distinguishes between principal diagnosis, admitting diagnosis, external cause of injury, and patient reason for visit codes," according to a MLN Matters article.

Start Preparing for Differences

Version 5010's implementation deadline will be here soon, so prepare now and be aware of three key changes:

• Dig into your claim forms to ensure that the beneficiary's information is accurate to the letter, or you'll face scores of denied claims on the new HIPAA 5010 forms. CMS will deny claims on which the beneficiary's name doesn't perfectly match how it's listed on his Medicare I.D. card when you begin using HIPAA 5010 form. Be sure to include suffixes whenever there is a one, such as Jr. or Sr. abbreviations. Enter the suffix exactly as it readson the patient's card, with or without the ending period. Though it seems like a tedious point, experts say entering different punctuation from the ID card might cause a denial.

• CMS will use several new error codes on claims once the 5010 form goes into effect. If you use a clearinghouse, discuss how these errors will be communicated to you and how these changes will impact your practice.

• Say goodbye to P.O. boxes, because post office boxes will no longer be permitted when reporting a billing provider's physical address. The new form does include an electronic field for the "pay to address" that allows a P.O. box.

Beware: The transition to 5010 is not just for practices that deal with Medicare, Weston warns. Some payers are even going active with version 5010 in August of this year, Brink says.

"Either directly or indirectly, HIPAA Version 5010 will impact nearly everyone involved in healthcare transactions -- providers, clearinghouses, and payers, as well as vendors who provide practice management (PM) systems and other transaction-related software(s)," says Kim Dues, CPC, owner of Mass Medical Billing Services in Dickinson, Tex. "It is mostly a complex technical issue for those on the business and administrative side. Although, if the implementation doesn't go smoothly, it will affect all."