Oct 28, 2011 (11:10 AM EDT)
Healthcare Providers Fear Disruptions With 5010 Standards

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Many healthcare providers worry about disruptions in cash flow when ANSI X12 version 5010 standards become mandatory for many electronic healthcare transactions starting in January--but there are good reasons for the change.

By all accounts, the conversion to ICD-10 coding for clinical diagnoses, required by Oct. 1, 2013, will be difficult, so it is essential to lay the groundwork with the adoption of 5010.

"Without 5010, we can't get to ICD-10," Regina Hayes, business office manager of Orthopaedic Specialists of the Carolinas in Winston-Salem, N.C., explained at the just-concluded Medical Group Management Association (MGMA) annual conference in Las Vegas.

According to Hayes, the 5010 data format can accommodate the longer field size for ICD-10 code--a maximum of 7 characters, up from the 5-byte limit in ICD-9 codes, with an extra digit added to indicate the version of ICD that a claim is linked to. (The latter feature might help with a future transition, too, as ICD-11 is already under development because ICD-10 has been used in other countries for more than a decade.)

[Legally, EHRs are double-edged swords: They protect clinicians from malpractice litigation but also put them at greater risk. See Will Your EHR Land You In Court?]

Version 5010 also increases the number of diagnosis codes allowed on a claim. Because the ambulatory side of ICD-10 contains five times the volume of codes as its predecessor, the extra capacity is essential, Hayes said.

The transition to 5010 from the 4010A1 standard that has been in effect since the advent of the Health Insurance Portability and Accountability Act (HIPAA) transactions rule in 2002 is intended to lower administrative costs, while the switch to ICD-10 coding in October 2013 is aimed at better reporting of clinical events, and, ideally, quality improvement. Processes are different, but preparations don't have to be, according to Hayes.

"All providers must relearn and rethink the diagnosis coding process," Hayes said about ICD-10. The new code set will require more than just "coding a bit differently." It calls for rethinking of workflows and even the renegotiation of payer contracts, as some agreements are based on care for patients with specific diagnoses or medical abnormalities and the granularity of ICD-10 provides degrees of specificity not possible with ICD-9. "ICD-10 will affect the entire practice," Hayes said. Certified coders will have to be recertified for ICD-10 by October 2012, Hayes said, and the change might finally force holdout physicians to give up their paper. "Paper superbills are going to be very challenging," with all the diagnostic codes, she added.

Younger physicians at Orthopaedic Specialists of the Carolinas have been "more accepting" of ICD-10, according to Hayes, which is helpful, because she believes ICD-10 planning time is dependent upon practice size. A small practice, with only a handful of physicians, has fewer staff members to train than a large medical group, she explained. Orthopaedic Specialists has 42 providers, including physicians, physician assistants, occupational therapists, and physical therapists, rather sizeable for a specialty practice.

Of course, the 5010 deadline is more pressing. According to a recent MGMA survey of its members, few group physician practices are completely ready for the transition, even though it is barely more than two months away.

If the MGMA gets its way and the federal government allows for contingency plans--something that might be inevitable at this point--so providers can continue to get paid after Jan. 1, it is not too late to start testing new 5010 processes. "If you have not yet started, do it now," Hayes advised.

"Once the vendors have told you they're ready to test, you need to work through the entire length of the claim."