If you work in the healthcare industry, you should make sure that you are aware and prepared for one of the largest updates affecting anyone who currently works in the industry; the implementation and required use of the new ICD-10 codes for insurance claims reimbursement and Version 5010 for all HIPAA electronic transactions transmitted by a covered entity under HIPAA law.  Covered entities by law do not include; worker's compensation or auto insurance carriers.

 

For all providers, including medical service facilities, in order to obtain reimbursement for claims submitted to any insurance carrier (health insurance, workers compensation and auto insurance), you must show the medical necessity for services rendered by accurately completing an insurance claim form called the CMS-1500.  Currently, the correlation of medical necessity is shown by linking the proper diagnosis code (ICD-9) and procedure code (CPT-4).  The form can be submitted to the carrier either by mail or electronically.  In most cases, many health insurance carriers, such as Medicare and Medicaid, will only accept claims submitted electronically.  Electronic claims are formatted and transmitted with specific software using the current Version 4010 (v.4010).

 

The current programs and coding used have been in effect for decades and therefore is in desperate need of a major overhaul to meet the requirements necessary under HIPAA and other healthcare laws for accurate claims submission, reporting and community health statistics tracking purposes.  That overhaul is now taking place!

 

As of January 1, 2010, external testing had begun with various companies who make electronic claims processing possible for the use of the new Version 5010 (v.5010).  On January 1, 2012 all HIPAA electronic transactions must use Version 5010. There will be a discretionary period until March 31, 2011 before fines will be assessed for non-compliance. If you have software in house that your office uses, have you begun the necessary testing?  What if you outsource these services-has your outsource company began testing?  What about your clearinghouse you may use as the go-between of claims transmission to the insurance carrier?  Are they ready for the January 1, 2012 deadline?  If you are unsure of the answer to any of these questions, or your answer is NO, then you need to pick up the pace or get left behind. Failure to be ready could mean a suspension in your claims reimbursement, which will effect your bottom line.(http://www.cms.gov/ICD10/)

 

With the current coding system, far too many claims are submitted as unspecified, because there isn't a code that exactly matches the patients diagnosis, and/or the provider has to use multiple codes to try to explain the diagnosis in as much detail as possible.  Remembering that a claim must link the correct diagnosis code(s) and procedure code(s) to show medical necessity, the current diagnosis coding system just isn't sufficient. 

 

 

There are numerous ways this may affect your practice.  Not only are you required to use the new ICD-10 codes on October 1, 2013, you may also need to:

 

*  Update software programs to add the new codes

*  Update documents used at your office (Superbills, ABNs, Referrals, Labs Requests)

*  Training for office staff (providers, coders, etc)

*  Budget and Productivity

*  Implementation Cost

 

too name a few.  As you can see, this change will affect everyone!  If you have not begun preparing, you will be caught off guard and your cash flow for your practice will suffer.

 

While worker's compensation and auto injury carriers are not required by law to switch to the new coding system, it may hinder how things work with them also and therefore you may expect that they will.  While the switch will go into effect on October 1, 2013, you will still have to finish handling claims submitted prior to that date using the ICD-9 coding system.  So, you will have two entirely different systems to manage for a little while. Are you prepared???

 

Rill Unique Enterprises will be ready.  Our software already supports v.5010 and testing is being completed so that everything works fine on the January 1, 2012 deadline.  We have also begun preparation for the mandate of October 1, 2013 for implementation and use of the new ICD-10.  Make sure that your practice is ready, and if you need our assistance, we will gladly help.  You may contact us by email request to customerservice@rilluniqueenterprises.com or by phone at (720) 338-7578.  You may also visit our Contact Us page.