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ICD-10 & HIPAA 5010 Resource Center
ICD-10 & HIPAA 5010 Resource Center
HIPAA 5010 is here! And ICD-10 is on the horizon. We remain committed to continue to communicate ICD-10 updates through our provider newsletter and other communications, this section of the website is intended to provide the most current information and resources available relating to ICD-10 implementation.
Read our latest update below.
HIPAA 5010 is here!
Frequently Asked Questions

What is HIPAA 5010?

For more than a decade, electronic transactions in the health care industry have been regulated by rules and standards established by the Health Insurance Portability and Accountability Act (HIPAA) of 1996. On January 16, 2009, modifications to the HIPAA Electronic Transaction Standards Final Rule were published. The Final Rule is applicable to all covered entities, including all health care providers, health care clearinghouses and business associates that use HIPAA transactions, such as billing services and agents.
The modifications mandate replaces prior standards as follows:
  • Version 5010 replaces the old version of the ANSI X12 standards for HIPAA transactions.
  • Version D.0 replaces the old version of the National Council for Prescription Drug Program standards for pharmacy and supplier transactions.

What is changing and why is the change needed?

This is the first major version change since HIPAA implementation. The new version enhances the business functionality, clarifies some ambiguities and better defines situational and required data elements.
Changes include:
  • Full support of NPI reporting
  • Full support of the new ICD-10 codes
  • Prohibited use of P.O. box for billing provider address
  • Requires 9-digit Zip code at billing and service provider loops
  • Accepts assignment (2300) CLM07 now used for provider to accept assignment with the payer. Previously, this segment was used for Medicare par status only.
  • Changes made to the AMT segments for COB claims (approved and allowed deleted)
  • Expands the number of diagnosis codes to 12
  • Date of service range only required when from and to are different (RD8)
  • Pay-to-provider address required when different than the billing provider

How does HIPAA 5010 impact me?

If you do not convert to HIPAA 5010 by the January 1, 2012, compliance date, your claims and other transactions will be rejected. Reimbursement delays and resubmission costs could occur, so it is important to prepare NOW.
HIPAA 5010 will apply if you:
  • Currently use version 4010 or 4010A1 of the standard electronic transactions
  • Wish to begin electronically reporting or inquiring about health care transactions
Can I continue to use paper claims after the mandate is in effect?
  • Electronic transactions offer efficiencies in claims filing and inquiries. We encourage you to consider adopting an electronic approach. HIPAA does not require you to switch.

How do I prepare?

If you haven’t already started planning, start NOW! Talk with your vendor or clearinghouse.
  • Confirm that your vendors, clearinghouses and other partners can support 5010 requirements and ICD-10.
  • Ask questions…
    • Will they upgrade your current system? Is there a charge?
    • Will the upgrade include transactions acknowledgements - 999 & 277CA?
    • Will they support both 4010A1 and version 5010 concurrently?
    • When can you begin testing?
    • Will they complete their transition prior to the January 1, 2012, compliance date?
  • Review contracts for terms related to honoring federal mandates or amend contracts as needed
  • Make sure you have the same understanding of the changes
  • Obtain timelines and project plans
  • Review the Readiness Checklist (PDF) to help ensure a smooth transition.
Certification Instructions & Companion Guide
Excellus BCBS Companion Guide (PDF) for the following transactions:
  • ASC X12N/005010X223 Health Care Claim Institutional (837)
  • ASC X12N/005010X222 Health Care Claim Professional (837)
  • ASC X12N/005010X221 Health Care Claim Payment/Advice (835)
  • ASC X12C/005010X231 Implementation Acknowledgement for Health Care Insurance (999)
  • ASC X12N/005010X214 Health Care Claim Acknowledgement (277)
Online Resources
Internet resources to keep you current on HIPAA 5010:
Questions?
Implementation questions can be emailed to EDI Solutions.
In the near future, all HIPAA-covered entities must use the new ICD-10 code sets.
The current ICD-9 code sets are out-of-date due to their limited ability to accommodate new procedures and diagnoses. ICD-10 incorporates greater specificity of codes - more clinical information contained in the codes - and updated terminology.
Use of ICD-10 will:
  • Improve the ability to measure health care services
  • Enhance the ability to monitor the populations' health
  • Provide better overall data and decrease the need for supporting documentation needed when submitting claims
Implementation Timeline
Access the timelines on the CMS web site to ensure your office or facility is ICD-10-ready! http://www.cms.gov/Medicare/Coding/ICD10/ICD-10ImplementationTimelines.html
Frequently Asked Questions

What is ICD-10?

In the near future, all health care entities must use ICD-10 codes on HIPAA transactions, including:
  • Diagnosis codes (ICD-10-CM) used by all providers in every health care setting
  • Procedure codes (ICD-10-PCS) only used for hospital claims and inpatient hospital procedures

What is different?

ICD-10 codes length and structure differ from ICD-9 codes. In addition, ICD-10 codes:
  • Contain more detail about conditions, injuries and illnesses
  • Include the concept of laterality
  • Use combination codes to describe conditions and associated symptoms
  • Use updated language and terminology

How do I prepare?

  • Learn about the structure and differences of the ICD-10 code set
  • Look at your organization and see what it will take to make the change
  • Coders will need to be trained on ICD-10. CMS recommends that this occur six to nine months prior to implementation
  • Talk with your vendors, payers, clearinghouses, billing services about ICD-10 readiness
  • Start to prepare for ICD-10 now!
  • Review the Readiness Checklists via the CMS website to help ensure a smooth transition at: http://www.cms.gov/Medicare/Coding/ICD10/ICD-10ImplementationTimelines.html

What is Excellus BCBS's position on ICD-10 implementation?

Follow this link to learn more about our position on ICD-10 implementation. (PDF)
Online Resources
For more information on ICD-10:
View our Navigating ICD-10 Training Presentation at the: Staff Training & Education page
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