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Home > Health Plans > 5010 and ICD-10
5010 and ICD-10:

ANSI 5010 Compliance

The Healthcare industry is currently undergoing the migration from ANSI 4010 to ANSI 5010 formats to meet the compliance deadline of Jan 1, 2010.

The new ANSI 5010 standard provides some useful changes for the Claims transaction, such as a designated location for the POA indicator; a move from the K3 segment in 4010 to HI segment; a separation in diagnosis code reporting; a clarified use of NPI; required minutes for anesthesia as opposed to units or minutes; a greater consistency between dental and professional claims; and a simplification of COB requirements.

Eligibility -major impact

  • Adds additional benefit categories and service type codes (CORE recommendations)
  • Clarifies dependent and subscriber relationships
  • Support the required alternate searches in the 270

Claims Status -medium impact

  • Allows prescription number reporting
  • Eliminates sensitive information to satisfy privacy concerns
  • Instructions for batch and real time use

Premium Payments -medium impact

  • Allows for additional payment deductions
  • Premium remittance detail information now required

Referrals/Pre-Authorizations -medium impact

  • Adds necessary functionality for use
  • Specific information on conditions
  • Number of occurrences
  • Separate segments for key patient conditions
  • Supports and expands authorization exchanges
  • Will allow use of this transaction to meet business needs

Remittance Advice -minor impact

  • Less than 5% structural changes from 4010A1 to 5010
  • Clarifies rules for use
  • Eliminates "not advised" elements
  • Clarifies and strengthens rules for balancing
  • Can be used with 4010 claims
  • Includes new medical policy segment

Enrollment -minor impact

  • Improves privacy protection
  • Adds information such as enrollment subtotals and coverage reasons
Tasks Details
Pre-Engagement Client to provide:
-Inventory of affected EDI Translation maps and transaction processes
-Layouts of proprietary data record formats and schemas
-Crosswalk references  between EDI standards & transaction processes (Ex: business edits, pre/post processing activities)
Phase 1:
EDI System Architecture
& Design Review
ORBIT Staff will:
-Review current system wide architecture
-Review current process flow for compliance
-Review current processes  for error checking and recovery
-Produce an implementation plan entailing the Development Cycle delivery dates, and resources required.
Phase 2:
EDI Transition
Development
Based on architectures and designs from Phase 1, ORBIT will:
-Develop 5010 versions of all required EDI translation maps and business processes
-Assist client EDI analysts in understanding and maintaining the maps and business processes
-Perform Unit testing on all developed or upgraded components
Phase 3:
System Deliverables,
Documentation &
Knowledge Transfer
Once the EDI system is ready for deployment, ORBIT will deliver:
-Full integration of the EDI system with all other systems it interacts with
-Completed translation maps, tested to meet Client specs
-Comprehensive documentation for each developed map, or extra Client requirements
-Complete knowledge transfer sessions for the Client staff
ICD-10 Compliance Consulting
Assessment. Planning. Remediation

Never before has the healthcare industry been faced with the challenge of simultaneously meeting a plethora of new regulations and deadlines and trying to comply with them with ever-tightening budgets. ICD-10 compliance is one of these critical deadlines that the industry has to meet. By October 1, 2013 all healthcare entities are required to upgrade their systems to be able to use and conduct transactions using ICD-10. Given the complexity of ICD-10 and the range of systems and processes, both clinical and financial, that it affects, it is critical that you assess its impacts and have a remediation plan in place at the earliest possible.

ICD-9 codes being used in the US Healthcare industry are outdated and have limited ability to accommodate new procedures and diagnosis. Furthermore, ICD-9 codes:

  • Lack the precision needed for a number of emerging uses such as pay-for-performance and bio-surveillance.
  • Limit the precision of diagnosis-related groups (DRGs)
  • Lack specificity and detail
  • Will eventually run out of space, particularly for procedure codes

The primary incentive for migrating to ICD-10 code set is the greater level of granularity and specificity for diagnosis and procedure codes that it provides. This richer clinical data will help develop better clinical pathways and hence better disease management and healthcare outcomes. It will also provide an opportunity for differentiated reimbursement for complex cases and improved access to healthcare information. Thus, while there will be significant technical, operational and financial challenges for achieving ICD-10 compliance, there are substantial long term benefits of this migration. This effort will require collaboration among providers, payers, software vendors, government entities and other business partners across the healthcare industry.

According to several experts, the cost of ICD-10 migration could be ten times that of Y2K. Though Health and Human Services (HHS) has changed the implementation date from Oct 2011 to Oct 2013 once, it is unlikely that the date will be changed again as US lags behind almost the entire world in ICD-10 adoption. Therefore, it is prudent that you plan your ICD-10 remediation efforts now to avoid the last minute crunch. IGI Health can be your partner in a successful ICD-10 migration.

IGI Health has a proven track record of assisting its clients in the healthcare industry meet regulatory deadlines in a timely and cost-effective fashion. Our suite of solutions and services will help you quickly assess the impacted systems and processes, determine the potential cost of ICD-10 migration and put together an optimal plan to achieve ICD-10 compliance well ahead of the deadline. But you need to start now.

IGI Health's ICD-10 Consulting Services:

IGI Health provides a complete suite of ICD-10 compliance services that will allow your organization to be ready well in advance for the compliance deadline. The services include:

1. Comprehensive ICD-10 Readiness Assessment
2. Remediation Planning
3. Implementation and Project Management
4. ICD-10 Implementation Testing
5. ICD-10 Training
     
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