Ch. 05


Getting ICD-10 and HIPAA Version 5010 up and running is going to be a long and daunting task, so it’s best to be prepared before hand. You should already have hit some of the check points for implementation, but whether you have or not, this helpful guide should make the process a little easier to get through.

Implementation Time Line:

  • By January 1st, 2010: Payers and providers should have began internal testing of HIPAA Version 5010 standards, to make sure the program is running smoothly well in advance of deadlines.
  • By December 31st, 2010: Payers and providers should have completed internal testing of version 5010 by this date. This is the first checkpoint for compliance, so it should be completed. If you haven’t completed it yet, get it done soon, because most people have already moved on to external testing.
  • By January 1st, 2011: Payers and providers began external testing of HIPAA Version 5010. The Centers for Medicare & Medicaid Services (CMS) began accepting 5010 claims on this date, but HIPAA Version 4010 claims are still accepted.
  • By December 31st, 2011: Payers and providers should complete external testing of HIPAA Version 5010. This is the checkpoint for compliance, so make sure it’s marked on your calendar.
  • By January 1st, 2012: All electronic claims submitted to CMS must use version 5010, as 4010 claims will no longer be accepted. If you aren’t version 5010 compliant by this point, you aren’t going to be able to submit your claims.
  • By October 1st, 2013: All claims for medical diagnoses and inpatient procedures must use ICD-10 codes by this date. The change does not affect CPT codes, which will continue to be used for outpatient services.
  • UPDATE: The U.S Senate  introduced a bill on March, 26st, 2014 that will delay the change of ICD-9-CM to ICD-10-CM until October 1st, 2015.

Meeting this time line will take a lot of foresight and forward planning. The amount of training needed is quite large, and you will have to budget both time and money to account for it. Outside professionals will need to be hired into your hospital for training, or you may have to send employees away to training boot camps or seminars. There are lots of training options available, so make sure you do your research and pick the one that makes the most fiscal sense for your company, especially if you are a vendor and your clients are relying on your software to help them through the transition.

Here are some resources to help you find a training program:

About the Code

The most notable change from ICD-9 to ICD-10 is actually the number of digits used in the code. Instead of the familiar five digits, ICD-10 will have seven digits, which break down as follows:

  • 1st digit: alphabetical (A-Z, not case sensitive)
  • 2nd digit: numerical
  • 3rd digit: alphabetical (A-Z, not case sensitive) or numerical, depending on the diagnosis
  • 4th-7th digits: alphabetical (A-Z, not case sensitive)

Because the new code is longer than the old, databases than you translate will take up more space than

Some areas of your business are going to be more heavily affected by the code change than others. You should focus your training efforts in these areas, and then work out from there. These areas are as follows:

  1. Claims Processing – For part A/B, the new system uses the Fiscal Intermediary Standard System (FISS), which is also used by fee-for-service (FFS)/Fiscal Intermediaries (Fis)/Medicare Administrative Contractors (MACs). FISS essentially edits institutional claims for consistency and administrative purposes. For non-institutional medicare claims under Part B, you have to use the Multi-Carrier Systems (MCS) for both physicians and non-physician practitioners.
  2. Payment Policies – Medicare payment policy will be refined under CMS, responding to the changes that have happened over the years. Anyone working with FFS will have to have a clear understanding of the new code, as it affects payment policies significantly.
  3. CMS System Repositories – System repositories and their data outputs process, including management and storage of CMS claims, will be affected by the change. Each system will need updated algorithms, characters and field lengths. In order to facilitate data trending analysis, ICD-9 coded files will need to be translated into ICD-10.
  4. Quality Measures and Payment Initiatives – Measure specifications and algorithms are developed using ICD-9 codes, which means that they will all have to be re-developed to accommodate ICD-10 codes. While mapping tools do exist, the translation is not exact, and it would be better to just re-calculate the algorithms. The following payment initiatives have incentives for development, which you may want to keep in mind:
    1. PQRI program – for physicians and other outpatient practitioners
    2. RHQDAPU program – for inpatient hospitals
    3. HOP QDRP – for outpatient hospitals
  5. Assessment Tools – The process for developing, collecting and reporting assessment instrument data in most facilities will be affected by the coding change. They will need to be re-programmed and reformatted for ICD-10.
  6. Risk Adjustment – Because risk scores are calculated using lots of different data points, including ICD-9 codes, the code change will affect risk adjustment systems. Each individual system will need to be evaluated for the change over to ICD-10.
  7. Quality Improvement Activities – QIOs will be just as affected by the ICD-10 change as other medical facilities. Because QIOs are responsible for ensuring that medicare is only paying for necessary and appropriate treatments, understanding of diagnosis codes is key.

For more detailed coverage of this, visit the CMS ICD-10 Planning Executive Report Summary.

There are lots of summaries and information guides online that can help you figure out how, exactly ICD-10 affects your organization. Here are some resources to guide you through the transition:

Medical Billing and Coding Online