Coding changes on the horizon
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Physicians and practice managers stress early preparation for looming 5010 and ICD-10 deadlines

For physicians and practice managers, the upcoming required transition to the 5010 version of the HIPAA transaction code sets and the ICD-10-CM diagnosis codes is a matter of vital importance. The interlinked transition will require a great deal of work on the part of physicians — especially those in smaller practices that may not have an abundance of resources to devote to educating their office managers and coders. The 5010 standards must be met by Jan. 1, 2012, and lead directly to the mandatory adoption of the new ICD-10 code set by Oct. 1, 2013. Working with vendors, pursuing early education, and creating a transition plan for staff will prove critical for an uninterrupted transition.

The 5010 transition

The upcoming transition to 5010 entails a change to the electronic data transaction standards under HIPAA, replacing the current 4010 standards. It affects every practice that electronically submits HIPAA transactions including patient eligibility checks, claims filing, or receiving remittance advice — whether directly to an insurance provider or through a clearinghouse. The 5010 transition is aimed at fixing a number of technical issues identified under 4010 and making more billing and insurance information available to health care providers. Additionally, the adoption of the new ICD-10 code set — mandatory October 2013 — cannot happen until the 5010 standards have been adopted. The relatively short period of time between the two deadlines highlights the need to prepare oneself and one’s practice as early as possible. [pagebreak]

With a great deal of billing work done electronically, practice management consultant Margret Amatayakul stresses the importance of clear and frequent communication with vendors — including practice management software providers, clearinghouses, and health insurance payers — in advance of the 5010 switchover. They are ultimately the ones responsible for implementing the necessary updates. Vendors, she said, should have already started testing by the beginning of 2010.

“For practice owners, their vendor is going to be their primary focus in terms of making sure that their practice management system is updated with whatever changes are needed,” Amatayakul said. “If they have not heard from their vendor, then they should contact them as soon as possible.”

“If they are using a clearinghouse or billing service, they should be in touch with them to make sure they know what they’re doing. I think that for the average physician, that’s probably not going to be an enormous deal, but they do need to make sure that something is happening. They don’t want to have their claims delayed because they’re not in compliance [with 5010] by Jan. 1 of next year. I think that’s probably sufficient for most practices.”

Melinda Lomax, executive committee member for the Association of Dermatology Administrators and Managers (ADAM), agreed, saying that the importance of confirming that the vendor and practice are both 100 percent prepared on Jan. 1 cannot be overstated. [pagebreak]

“The first thing I think we need to do now is communicate with our software vendors and practice management people and make sure they’re testing for 5010 now,” she said. “Will they be ready to transmit/submit by Jan. 1 of next year?”

Reston, Va., dermatologist Maithily Nandedkar, MD, said that she relies extensively on the vendor to see her practice through the vital 5010 transition, as the demands of her small practice leave her and her employees little time to grapple with the minutiae of the transition.

“It’s just making the time to deal with the change,” Dr. Nandedkar said. “We are relying heavily on our vendor. Luckily, they’re very much on top of the situation. What I’ve learned is that you’ve got to ask, not assume. That’s a lesson learned for me.”

Educating your practice on ICD-10

Following the transition to the 5010 transaction standards, practices will be able to pursue adoption of the ICD-10 code set, which replaces ICD-9, volumes I and II. As the first complete revision of the ICD-9 code set in 30 years, the transition may seem intimidating to physicians who are used to previous revisions. But according to Lomax, the changes for dermatology are minor — especially in comparison to other specialties. [pagebreak]

“I’ve seen a lot of the proposed changes, and our specialty doesn’t seem to be as involved as others,” Lomax said. “Dermatology diagnoses are going to be very specific to the location and the symptoms. There are specific diagnoses used in each office that need to be evaluated — what is documented in each patient’s record, which codes are used more often, and how will that cross over into the new coding?”

Dr. Nandedkar noted that much of the most important information for practitioners and managers can be found through the Centers for Medicare and Medicaid Services (CMS) website and the American Academy of Dermatology’s resources on the transition.

“The CMS website is amazing. On 5010 and ICD-10, it’s excellent. It gives the timeline of what’s required of us and I know that like most physicians, I’m really busy and grateful to be able to find that information at a glance,” Dr. Nandedkar said. “My staff and I will be taking a course and talking to Medicare about how best to do the upgrade for ICD-10. We need to use our Academy to our advantage.” (See sidebar for information on resources available from the Academy, CMS, and others.)

In addition to the government resources available and internal resources, ADAM board member and University of Missouri School of Medicine practice manager Pamela Matheny, M.B.A., said that many of the professional management and coding organizations are stepping up their educational offerings with deadlines looming. [pagebreak]

“ADAM is taking a proactive approach. At our annual meetings this year, in 2012, and in 2013, we’re going to have a lot of ICD-10 sessions for those that don’t have the resources of a large institution to begin preparing themselves for ICD-10,” Matheny said. “I think it’s just a matter of being very prepared. We’re going to help a lot of people get prepared so that they can hit the ground running. I think we’ll be able to have enough planning in advance that it’s going to be a pretty smooth process.”

Planning for change

According to Matheny, physicians and managers have plenty of time to adapt to the upcoming changes so long as they’re willing to implement an education plan where necessary for support staff. While it’s unclear this early on exactly how choosing a code during a typical day will change, she said, her organization is willing to put the resources behind early education in hope of a quick start when the changeover occurs. (For more specifics on how codes will change, see Answers in Practice)

“It’s very hard to make people aware of the fact that what’s happening in the ICD-10 has to do with anatomy, and you really need a clear understanding of anatomy — whether there’s two of something, whether there’s a left and right, that kind of thing,” Matheny said. She said that non-clinical staff may need a new kind of training. “Dermatologists should send them for training, not necessarily for ICD-10 right away, but it wouldn’t be a bad idea for staff members to start brushing up on anatomy if they don’t know it really well. Physicians know anatomy, but their administrators and managers may not have a whole lot of that.” [pagebreak]

In order to recognize and address the specific needs of your staff and practice during the change, Lomax advises a measured plan for absorbing the new material.

“One thing I think [practices] need to be doing now is to develop a task force to assess our needs and the changes that are going to happen in our office and keep everyone updated in the process,” Lomax said. “This is definitely not going to be a one-person job. Everyone’s going to have something to do with ICD-10 whether they realize it or not. Your task force is really going to be identifying all these processes and changes,” she said.

“By the fourth quarter of 2012, I plan on working with all my physicians and providers and my clinical staff on documentation,” Lomax added. “I think that’s going to be the key to choosing what codes you need. Their documentation is going to have to change. And at that point, we won’t know for sure what we need to do, but I do think we need to start working on more thorough documentation in order to choose the right diagnosis code set,” she said.

In identifying the codes, Lomax said, practices will be able to speed their conversion with the use of the General Equivalence Mapping (GEM) tool. The utility, developed by CMS, acts as a two-way translation resource between ICD-9 and ICD-10 codes. She said, however, that GEM has been designed and released as a guide for practices, rather than a full conversion plan. It cannot fully address the increased complexity of the ICD-10 conversion.

“By the first quarter of 2013 we should be able to identify the codes that are specific to dermatology, and every practice is probably going to have to go through and identify those that they use the most. The GEM tool will help them know which codes are going to replace those that they’ve been using. By the same time, we’re going to need to start implementing those changes in process that we’ve talked about in 2012. Hopefully, then, by Oct. 1, 2013, we’d be ready to use them.” [pagebreak]

Matheny said that in light of the myriad educational sessions being offered well in advance of the deadline, beginning the educational process early is a wise decision.

“Dermatologists shouldn’t wait until the last minute. They need to send their practice managers and coders to some of the professional events and take advantage of the resources of larger organizations. It will help them come up to speed on the coding,” Matheny said. “Their local American Academy of Professional Coders (AAPC) chapters will help as well. They’re going to have to rely on the AAD and ADAM in order to get that derm-specific coding information that they’re going to need,” she said.

Physicians hoping to get an early start on the 5010 and ICD-10 conversion process should acquaint themselves with the information available on the CMS website (see sidebar on implementation resources), as well as the educational resources provided by the Academy, ADAM, and the AAPC. Each of these organizations is committed to ensuring a smooth transition for the 5010 and ICD-10 deadlines.

5010 and ICD-10 deadlines

Jan. 1, 2012: Use of 5010 version of the HIPAA Transactions and Code Sets required.

Oct. 1, 2012: A National Health Plan Identifier Number must be adopted. This will give practices better information about who to contact for claims processing information.

Jan. 1, 2013: New operating rules for eligibility and claims status transactions go into effect. These rules address the electronic exchange of information, and will be standardized across health plans. Coupled with 5010, this set of regulations will enable easier real-time transactions. The following transaction sets will be affected:

  • 837 Claims/Encounter
  • 835 Claim Payment/Remittance Advice
  • 270/271 Eligibility Inquiry/Response
  • 276/277 Claim Status Request/Response
  • 278 Health Care Services Review Request
  • 820 Premium Payments
  • 834 Health Plan Enrollment

Oct. 1, 2013: ICD-10-CM use becomes mandatory

Implementation resources

A wide variety of resources are available for physicians, other clinical staff, managers, and coders to familiarize themselves with the 5010 standards and ICD-10.

American Academy of Dermatology

ICD-10 resources:

Getting Ready for ICD-10 Webinar:

Center for Medicare and Medicaid Services


Version 5010:

American Academy of Professional Coders

ICD-10 Hub (includes 5010 information):

American Health Information Management Association


5010 transition checklist

To smooth the 5010 transition process, experts recommend the following steps for physicians.

  • Create an implementation team and transition plan — Identify those most likely to be impacted by the transition, gather them to form a transition plan, and hold regular meetings to discuss and document the ongoing progress of the transition.
  • Contact your vendors — Ask your vendors to provide you with information about when specific steps toward the transition will be taken and what you need to do to ensure your practice’s transition plans coordinate with the vendor’s.
  • Utilize testing schedules — Compile a list of your vendors and their test schedules. Keep track of the vendor’s progress, along with your practice’s.
  • Update your EHR software — Communicate with your software vendor to update to the latest version and harness the benefits of 5010. Budget for the time and expense of any upgrade costs and downtime.
  • Train your staff — Keep yourself and your staff knowledgeable throughout the process by taking advantage of classes, webinars, and online information. Budget for additional staff training, if necessary.
  • Test your system — Utilize extensive internal testing on practice processes at the minimum. It may also help to undergo external testing, should time and budget allow.
  • Monitor your operations — Log any and all issues, and periodically review data to check whether certain problems tend to repeat. Pay special attention to your payer rejection/denial percentages and your reimbursement. Contact vendors if problems persist.

(Source: American Academy of Professional Coders,



5010 and ICD-10 deadlines
Implementation resources
5010 transition checklist