1. Sherry Thomas, CCP, CCP-AS CEO/Director of Education
ICD-10-CM:
Are you in compliance?
Sherry Thomas, CCP, CCP-AS
CEO/Director of Education

2. ICD-10…will this really happen?
PER CMS:
“These transition dates are definite. The U.S. Depart.
of Health and Human Services (HHS) established the
deadlines in two final regulations issued on January 16,
2009, and confirmed them on March 5, HHS does
not plan to extend the deadlines.”
©2010 PHIA/Medical Staff SOS,. Inc

3. Implementation date… October 1, 2013
Based on the process for adoption of standard under the Health
Insurance Portability and Accountability Act of 1996 (HIPAA).
FINAL RULE for adoption of:
ICD-10-CM (physician/out-pt)
ICD-10-PCS (hospital)
January 16, 2009
Federal Registry: 45 CFR part 162 [CMS-0013-F]
Vol. 74, No. 11, Page
©2010 PHIA/Medical Staff SOS,. Inc

4. Per CMS… Effective Date of the regulation: March 17, 2009
Level I Compliance by: December 31, 2010
Level II Compliance by: December 31, 2011
All covered entities have to be fully compliant on: January 1, 2012
©2010 PHIA/Medical Staff SOS,. Inc

5. DATE COMPLIANCE STEPS January 1, 2010
Payers and providers should begin internal testing of Version 5010 standards for electronic claims.
December 31, 2010
Internal testing of Version 5010 must be complete to achieve Level I Version 5010 compliance.
January 1, 2011
▪ Payers and providers should begin external testing of
version 5010 for electronic claims
▪ CMS begins accepting Version 5010 claims
▪ Version 4010 claims continue to be accepted
December 31, 2011
External testing of Version 5010 for electronic claims must be complete to achieve Level II Version 5010 compliance
January 1, 2012
▪ All electronic claims must use Version 5010
▪ Version 4010 claims are no longer accepted
October 1, 2013
▪ Claims for services provided on or after this date
must use ICD-10 codes for medical diagnosis and
inpatient procedures.
▪ CPT codes will continue to be used for outpatient
services.

6. 4010 Transactions Required now for transmitting claims
Payers could develop X12 files:
according to their own companion guides
could adopt their own modifications
Heathcare needed a better way to transmit data
5010 developed
Companion guides will still be needed with 5010 but
will be more standardized
©2010 PHIA/Medical Staff SOS,. Inc

7. Why 5010? Mandated by HHS www.hhs.gov Passed Final Rule 2009
(US Dept. of Health & Human Services)
Passed Final Rule 2009
January 1, 2012 claims processing will no longer accept 4010 transactions
Required for transmitting ICD-10 codes on October 1, 2013
Needed for insertion of 5 – 7 characters required for ICD-10
Increases number of diagnosis code on claim
©2010 PHIA/Medical Staff SOS,. Inc

8. Level I Compliance December 31, 2010
“A covered entity can demonstrably create and receive compliant
transactions, resulting from the compliance of all
design/build activities and internal testing.“
Internal testing:
create and receive compliant transactions
keep record of this in your compliance manual
Some fields on 4010 will be deleted on 5010, some will be added
CMS:
Search for 5010
©2010 PHIA/Medical Staff SOS,. Inc

9. Steps to Level I Compliance
STEP 1: Purchase TR3
STEP 2: Plan of Action
STEP 3: Gap Analysis
STEP 4: Communication with Vendors
STEP 5: Education
©2010 PHIA/Medical Staff SOS,. Inc

10. “Technical Report Type 3” Washington Publishing Company
STEP 1: TR3 Document
“Technical Report Type 3”
X12
Washington Publishing Company
Publishes HIPAA Accredited Standards Committee (ASC) X12 TR3 document
©2010 PHIA/Medical Staff SOS,. Inc

11. STEP 2: Project Team and Plan of Action
Assign a project manager
Include IT personnel and all end users
Develop a measurement tool for tracking the project
Estimate financial impact of IT and business changes
©2010 PHIA/Medical Staff SOS,. Inc

12. STEP 3: Gap Analysis
Determines the system and business process changes required to create a plan, develop timelines and establish communication with all involved
©2010 PHIA/Medical Staff SOS,. Inc

13. Contact your software vendor(s)
Will your current hardware support the required upgrades?
File conversions and compatibility with the current version
When will your system be upgraded?
Does your license include regulation upgrades?
If no, will there be a charge for this?
Will the upgrade include “acknowledgement transaction 277CA and 999”?
Will the upgrade include a “readable error report” (produced from 277CA and 999 transactions).
©2010 PHIA/Medical Staff SOS,. Inc

14. Contact your clearinghouse vendor(s)
When will your vendor be ready to accept test files?
Does your contract include regulation upgrades?
If no, will there be a charge for this?
Will the upgrade include “acknowledgement transaction TA1, 277CA and 999”?
Will the upgrade include a “readable error report”
(produced from TA1, 277CA and 999 transactions).
©2010 PHIA/Medical Staff SOS,. Inc

15. * Check with vendors to see if they offer 277CA reporting!
Error Reports TA1, 277CA & 999
TA1 & 999 = Technical problem
 Contact the software vendor who prepares the EDI transmissions.
 Find out what corrections need to be made before resubmitting the
transmission.
277CA = Data problem
 Contact the billing staff
 Reports will have to be produced with the 277CA transaction in order
to determine the problem with the claim. Must be done before
resubmitting the transmission.
* Check with vendors to see if they offer 277CA reporting!
©2010 PHIA/Medical Staff SOS,. Inc

16. Error Reports continued…
TA1 = You will need to “correct/resubmit” the entire
ISA – IEA interchange
999 = Review syntax errors and begin a “correct/resubmit”
action
277CA = Review business rule errors and begin a
“correct/resubmit” action on specific claims.
Use returned claim numbers for future claim
status inquiries.
©2010 PHIA/Medical Staff SOS,. Inc

17. Clearinghouse vendor(s)continued…
When does your vendor plan to complete testing with third party payors?
Ask for a copy of their report
Can they convert 4010 to 5010 format?
Plan an alternative way to submit EDI transactions in case you are at risk for non-compliance.
©2010 PHIA/Medical Staff SOS,. Inc

18. How will this change affect your current business process?
5010
How will this change affect your
current business process?
What’s new, what was deleted and what was changed?
Do a comparison…….
10DO.asp
©2010 PHIA/Medical Staff SOS,. Inc

19. How will this affect your practice?
Determine which payors you do business with.
When do they plan implementation?
How will they inform you of changes and/or implementation dates?
Determine who your primary source for revenue is.
How will this change monetarily impact your practice?
©2010 PHIA/Medical Staff SOS,. Inc

20. STEP 4: Communication Keep everyone informed
Include your software and billing vendors in your process
Get contact name and information for questions
Will you need new IDs for your providers?
©2010 PHIA/Medical Staff SOS,. Inc

21. * Keep record of this in your compliance manual
STEP 5: Education
ALL providers and staff need to understand the transaction changes and how this will impact the practice
Provide education relating to:
Changes in software
Workflow processes
* Keep record of this in your compliance manual
©2010 PHIA/Medical Staff SOS,. Inc

22. Level II Compliance December 31, 2011
“A covered entity has completed end-to-end testing
with each of its trading partners,
and is able to operate in production mode
with the new versions of the standards.“
External testing with trading partners:
create, receive and submit compliant transactions
keep record of this in your compliance manual
©2010 PHIA/Medical Staff SOS,. Inc

23. Steps to Level II Compliance
STEP 1: Involve the vendors
STEP 2: Changes to data reporting
STEP 3: Identify modification changes
STEP 4: Education
STEP 5: Testing with vendors
©2010 PHIA/Medical Staff SOS,. Inc

24. STEP 1: Involve your vendor(s)
Work with your software/trading partner(s) to perform External testing
Per CMS…..
Software vendors are NOT responsible for compliance……YOU ARE!
Ask these questions:
Can they support 4010 & 5010 transaction exchanges concurrently?
When will installation of upgrades be finished?
When can you start sending “test” transactions?
Will the vendor change their fee regarding the new 5010 transaction?
©2010 PHIA/Medical Staff SOS,. Inc

25. STEP 2: Identify changes to data reporting requirements
5010 may require collection of additional data or reporting data in a different format.
Billing provider address can no longer be reported as a P.O. Box or lockbox address
Ask these questions:
Can we identify the data reporting changes for the transactions we use?
Can we find the resources to assist us in identifying the data reporting
changes and if so what is the cost of the resources?
Can this new data be stored in our current system or will it require a
system upgrade to store it?
Will we need to purchase additional hardware for the new reporting system?
©2010 PHIA/Medical Staff SOS,. Inc

26. STEP 3: Identify modification changes
Workflow modifications may need to be done
Ask these questions:
Will we need to alter our workflow processes in order to capture
the new data?
Will we incur additional costs associated with these new data
collection methods?
What will it cost us to modify our workflow processes?
©2010 PHIA/Medical Staff SOS,. Inc

27. STEP 4: Education
GOAL: Make sure transactions continue to be submitted, received, interpreted and responded to correctly using Version 5010
Ask these questions:
Who should receive training?
How long will training take?
What resources are needed for training?
What will it cost to provide training?
©2010 PHIA/Medical Staff SOS,. Inc

28. STEP 5: Testing procedures with vendors
GOAL: Complete “end to end” testing with success!
Ask these questions:
Which transactions should be tested?
When should we begin testing?
Which vendors should we test with?
Are we suppose to use “test data” or “live data” when performing
testing?
Keep record of this in your compliance manual
Must begin using 5010 on January 1, 2012
©2010 PHIA/Medical Staff SOS,. Inc

29. ICD-10-CM: Will you be ready?
Implementation date…
October 1, 2013

30. To achieve accurate submission of claims…
Joint effort between the healthcare provider and the coder
Consistent AND complete documentation in the medical record is IMPERATIVE!
FOR CODING ACCURACY:
ICD-10-CM suggests the “entire record” be reviewed to determine the specific “reason for the visit” AND the “condition(s) treated”.
©2010 PHIA/Medical Staff SOS,. Inc

31. through resources CMS National Provider Calls for 2010
Eligibility Request/Response
Professional Claim
Institutional Claim
Claim Status Request/Response
Remittance Advice
Acknowledgements
MAC Preparation & Outreach on
5010/D.O Implementations
©2010 PHIA/Medical Staff SOS,. Inc

32. This official CMS ICD-10 logo means that these materials were developed by CMS, and are intended for general industry use.
©2010 PHIA/Medical Staff SOS,. Inc

33. Additional Resources
ICD-10 final rule is available at
D d0.asp
©2010 PHIA/Medical Staff SOS,. Inc

34. Additional Resources www.ncvhs.hhs.gov/070730p4.pdf
TransactionsandCodeSetsRegulations.asp
©2010 PHIA/Medical Staff SOS,. Inc

35. Medical Staff SOS, Inc./PHIA
Sherry Thomas, CEO/ Director of Education
Certified Coding Professional (CCP)
Certified Coding Professional – Audit Specialist (CCP-AS)
30 years experience in healthcare
Clinical, Administrative, Education
Services includes:
Chart Auditing
Healthcare Seminars/Workshops
Qualified IRO - Integrity Agreements
National Credentialing Organization
ONLINE Coding/Billing Courses
(Certification/Diploma)
Provider/Staff Education
©2010 PHIA/Medical Staff SOS,. Inc

36. Thank you for joining me today!
For additional information please contact:
SHERRY THOMAS, CCP, CCP-AS
CEO/Director of Education
Medical Staff SOS, Inc./ PHIA
©2010 PHIA/Medical Staff SOS,. Inc