Major Changes for Insurance Claims Forthcoming

There are major changes currently occurring in health care that will affect the majority of us.

Here is a brief overview of a couple of hot topics.

HIPAA 5010

FROM: Centers for Medicare & Medicaid (CMS)

Standards for Electronic Transactions-New Versions, New Standard and New Code Set - Final Rules

On January 16, 2009, HHS published two final rules to adopt updated HIPAA standards; these rules are available at the Federal Register.

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. 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 theInternational 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.

Where does RANAC stand regarding the Level I Compliance for the HIPAA 5010 ERRATA Electronic Claims requirements?

The following paragraph is from NetPractice/Noteworthy regarding their readiness:

To assist in meeting Level I Compliance for the HIPAA 5010 ERRATA Electronic Claims requirements, numerous changes have been made. These changes are in preparation for you to begin sending 5010 claims, although full 5010 functionality will not be available until the release of 7.4.1. Claims are still being sent in 4010 format. The certification process for HIPAA 5010 ERRATA claims will begin on a payer-by-payer basis with the release of version 7.4.1. In version 7.4.1, we will be sending 4010 claims and will send 5010 claims as we become certified with each payer. This will ensure meeting the 5010 submission requirement deadline of January 1, 2012.

For practices using SuiteMed version 14 is in final testing and will be meeting the submission requirement deadline of January 1, 2012.

For practices currently using Practice Point Manager (PPM) there are no plans to updates to the 5010 submission requirements.

At the recent IMGMA Third Party Payer Meeting all of the carriers present (Anthem, Cigna/Sagamore, United Health Care, Medicare, Medicaid, Encore, Humana and Advantage Health Solutions stated they are currently testing and will meet the 5010 submission requirements.

So what this means to you is that for the time being you do not have to worry about the 5010. Unless you are currently using PPM, then you need to contact us so we can help you.

ICD-10

From: Centers for Medicare & Medicaid (CMS)

The compliance date for implementation of the International Classification of Diseases, 10th Edition, Procedure Coding System/Clinical Modification (ICD-10-PCS/CM) is October 1, 2013 for all covered entities. ICD-10-CM, including the ICD-10-CM Official Guidelines for Coding and Reporting, will replace the International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) diagnosis code set in all health care settings for diagnosis reporting with dates of service, or dates of discharge for inpatients, that occur on or after October 1, 2013. This publication discusses the benefits of ICD-10-CM, similarities and differences between the two coding systems, and new features and additional changes that can be found in ICD-10-CM.

BENEFITS OF ICD-10-CM

ICD-10-CM incorporates much greater clinical detail and specificity than ICD-9-CM. Terminology and disease classification have been updated to be consistent with current clinical practice. The modern classification system will provide much better data needed for:

Measuring the quality, safety, and efficacy of care;
Reducing the need for attachments to explain the patient’s condition;
Designing payment systems and processing claims for reimbursement;
Conducting research, epidemiological studies, and clinical trials;
Setting health policy;
Operational and strategic planning;
Designing health care delivery systems;
Monitoring resource utilization;
Improving clinical, financial, and administrative performance;
Preventing and detecting health care fraud and abuse; and
Tracking public health and risks

Non-specific codes still exist for use when the medical record documentation does not support a more specific code.

SIMILARITIES AND DIFFERENCES BETWEEN THE TWO CODING SYSTEMS

ICD-10-CM uses 3–7 alpha and numeric digits and full code titles, but the format is very much the same as ICD-9-CM (e.g., ICD-10-CM has the same hierarchical structure as ICD-9-CM).

The 7th character in ICD-10-CM is used in several chapters (e.g., the Obstetrics, Injury, Musculoskeletal, and External Cause chapters). It has a different meaning depending on the section where it is being used (e.g., in the Injury and External Cause sections, the 7th character classifies an initial encounter, subsequent encounter, or sequelae (late effect)).

Primarily, changes in ICD-10-CM are in its organization and structure, code composition, and level of detail.

ADDITIONAL CHANGES FOUND IN ICD-10-CM

The additional changes that can be found in ICD-10-CM are:

Injuries are grouped by anatomical site rather than by type of injury;
Category restructuring and code reorganization have occurred in a number of ICD-10-CM chapters, resulting in the classification of certain diseases and disorders that are different from ICD-9-CM;
Certain diseases have been reclassified to different chapters or sections in order to reflect current medical knowledge;
New code definitions (e.g., definition of acute myocardial infarction is now 4 weeks rather than 8 weeks); and
The codes corresponding to ICD-9-CM V codes (Factors Influencing Health Status and Contact with Health Services) and E codes (External Causes of Injury and Poisoning) are incorporated into the main classification rather than separated into supplementary classifications as they were in ICD-9-CM.

To find additional information about ICD-10-CM/PCS, visit http://www.cms.gov/ICD10/on the Centers for Medicare & Medicaid Services (CMS) website

FYI

ANTHEM has a new Claims filing address

For claims:
Anthem Blue Cross & Blue Shield
PO Box 105187
Atlanta, GA 30348

For Correspondence:
Anthem Blue Cross & Blue Shield
PO Box 105557
Atlanta, GA 30348

The Louisville KY address is still open and will continue to forward claims for a while yet.

CIGNA claims previously going to Scranton PA, are now going to Chattanooga, TN. Please see their web site for all the PO Box changes. Or, for questions about these changes, call Cigna at 1-800-882-4462.

Well that covers a few of the exciting things happening in health care. Please feel free to use this article to help you get to sleep at night. If you should have any questions please feel free to contact me at 317-819-0174.

- Theresa Wright -
Director of Medical Services
317.844.0141 ext. 226
800.844.0141 ext. 226
Direct #: 317.819.0174
theresaw@ranac.com