The next step for many healthcare providers is efficient health information exchange (HIE) across networks and better programs to coordinate care delivery, for which the new 5010 electronic data interchange standards is a vital component.
Implementing the 5010 transaction could require physician practices to upgrade or even replace their current information systems and modify their existing coding practices. The 5010 transition provides the framework to implement ICD-10, which creates a more detailed coding structure to describe diagnoses and procedures. The higher level of detail within the ICD-10 code set will help physician practices monitor the quality of their care delivery while participating in an increasing number of pay-for-performance programs.
Implementing the 5010 transaction offers providers several advantages. Payers and clearinghouses benefit from more streamlined processes and practices become enabled to better manage EDI transactions. 5010 transaction improvements also help healthcare providers achieve larger strategic goals, such as better connecting with HIEs and monitoring care quality measures that are vital to earn full reimbursement.
Recently, the Centers for Medicare & Medicaid Services' Office of E-Health Standards and Services announced that it is pushing back the deadline to begin enforcing 5010 standards from January 1 to March 31, 2012. However, practices should not wait to update their systems. Taking the time now to upgrade to a 5010-compliant system reduces practice risk associated with scheduling system upgrades and provides practices time to certify their systems works appropriately.
As ICD-10 codes will be required on all HIPAA transactions, all providers and their partners will need to make the transition. The present ICD-9 code is unable to support current functionality related to reporting. ICD-10 will be required for all outpatient claims on and after October 1, 2013.
There are two ways you can prepare for this transition: taking a passive approach or a proactive approach.
A passive approach forgoes an update and relies upon the EDI clearinghouse to map outbound EDI transactions from a practice to a clearinghouse that is 5010 compliant, where possible. The “where possible” may seem scary, but most experts agree that only a few claim types are thought to be un-mappable to 5010. These claim types include certain anesthesia claims, ambulance claims and some UB or hospital-based claims.
The downside of a passive approach is that you do not position your practice to take advantages of the data content changes that are primarily designed to benefit you. If you do not update your system, your vendor will map a 5010 version of eligibility responses and payment files to their 4010 counterparts so they can post into older versions of software.
The proactive approach is one where you work with your vendor to schedule and perform an upgrade of your system. Upgrading to the latest version not only enables 5010 data mapping natively in the software, but may also help your practice become ICD-10 enabled. You should evaluate your current vendor partner's ability to help you leverage these new data standards and determine your vendor's ability to help you address improving workflows (e.g. rejected claims management) in your practice.
While the passive approach may be unavoidable for some practices, I highly recommend you stay current with the latest version of your practice management system to maximize your EDI experience.
Running a successful practice in today's environment is complex. By using technology to replace manual processes, you free up time and energy to focus on more productive areas. Work with your software vendor to find ways to automate routine processes, and you will likely find successful ways to navigate the complexity.
Matthew J. Hawkins is the CEO of Vitera Healthcare Solutions, based in Tampa, Florida.