No Physician Pay in 2012 If Not e-Claim Compliant

“On January 1, 2012, if physicians’ practice management systems are not up to new standards, they will risk not getting electronic payments from private insurers and Medicare.

Despite that possibility, many physicians have not even begun to see if they are compliant with what are known as HIPAA Version 5010 standards. According to a survey released in March by the Medical Group Management Assn., 56% of practices have not scheduled any internal testing for 5010, and 61% have not scheduled any testing with their major health plans. The survey covered 349 practices with 13,290 doctors.

In January 2009, the Bush administration approved a rule, advocated by the American Medical Association and others, that moved the HIPAA 5010 deadline back from April 1, 2010, to Jan. 1, 2012. But experts say physicians shouldn’t expect any more time.

“Those who think that there’s going to be a last-minute delay announced in this are engaged in wishful thinking, and I certainly wouldn’t put my practice at risk by making a bet on that,” said Joe Miller, director of e-business at AmeriHealth Mercy, a Philadelphia-based Medicaid managed care contractor.

But physicians are not yet out of luck if they haven’t started making the changeover to 5010 — as long as they start the process soon.

“Understanding how the move to the newest version of the federal electronic transactions standard will affect a medical practice may seem overwhelming,” AMA President Cecil B. Wilson, MD, said in a statement. “But it is important, and not too late, to get started in order to avoid significant disruptions to patient care and claims payments.”

What is 5010?

The new data standards come out of the Health Insurance Portability and Accountability Act of 1996. The 4010 set was mandated in 2000 and has been revised since then. However, 4010 was recognized, as CMS put it, as “lacking certain functionality the health care industry needs,” and the agency issued a final rule in Jan. 16, 2009, that mandated the eventual use of 5010.

The new standard demands more specificity in what data must be entered and transmitted. The hope is that the claims process will be more efficient, that there will be less need to re-file claims because of errors and confusion, and that there will be greater detail about the patient visit.

For example, physicians must submit a nine-digit, rather than a five-digit, ZIP code on all claims submissions and submit a street address rather than a post office box. Also, 5010 allows physicians to distinguish between principal diagnosis, admitting diagnosis, external cause of injury and patient reason for visit codes.

HIPAA 5010 is also a precursor to the Oct. 1, 2013, adoption of ICD-10, the newest and most complex set of International Classification of Disease codes. The 5010 set will allow for the inclusion of ICD-10 codes, which 4010 can’t support.”

Read Emily Berry’s full article from amednews including a step-by-step guide for getting compliant HERE

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