De-mystifying 5010 versus ICD-10.

Although the published CMS resources on the transitions to 5010 and ICD-10 are actually quite clear, we still run across fairly pervasive confusion between the two. They are related but are not one and the same.

5010 is a transaction set that governs claims submission. It replaces the current 4010 series. Payers are converting to this higher standard as a precursor to the introduction of ICD-10. The compliance date was January 1, 2012 but an "enforcement discretion period" effectively extends it to March 31, 2012.

The 5010 changes apply to all HIPAA "covered entities". Confusion arises here because clearinghouses can appear to change the rules. They may tell software vendors or providers that the deadlines don't really apply or aren't as hard and fast as they're made out to be. What this means is that they, the clearinghouse are the covered entity and the provider is not. (If a provider does not use a clearinghouse and submits claims directly to the payer, then the provider is the covered entity.) So, when a clearinghouse is used, compliance applies strictly to the clearinghouse. The clearinghouse may then choose to extend grace to the provider by continuing to accept claims in the older format. As long as the clearinghouse completes the conversion to the new format (5010) and submits to the payer in that format, the requirement has been met.

ICD-10, by contrast, applies to diagnosis and procedure codes. They will replace the current ICD-9 codes but not CPT codes for outpatient billing. The compliance deadline for this step is October 1, 2013.

In both cases, the software vendor has work to do. Being ready for 5010 compliance is much simpler than ICD-10 compliance since the latter means reorganizing the EHRs around ICD-10 structures. ICD-10 is a better, more logical system (used worldwide), a much more comprehensive one than the current ICD-9s.

For the provider and provider staff, here's an important call to action. Yes, you need to be talking to your software vendor and hopefully hearing right and reassuring messages about the integration of ICD-10 codes into the EHR. But understand too, ICD-10 compliance is not all in your vendor's court. There's a significant learning curve for billing staff, akin to learning the metric system after growing up on imperial measures. Find the courses and workshops offered locally and at major conferences and tradeshows and get moving on that. This is another big piece in the transformation of health care that ultimately means the survival of your business.

For more detailed information on both 5010 and ICD-10, the CMS website has excellent resources - FAQs, checklists, widgets. Click here to go there ... and all the best!

Alistair Jackson, M.Ed.