Next Step in ICD-10 Conversion Coming January 1

The next stage in the transition to ICD-10 is just around the corner. The International Classification of Diseases (ICD) is a fundamental coding system used in billing, as well as keeping lists of diagnoses in Electronic Health Records (EHRs).

For many years (since 1975), the ICD system used in the U.S. has been ICD-9 (actually, its extension, ICD-9-CM), which are 3-5 digits in length and number over 14,000. The upcoming ICD-10 code set are 3-7 characters in length and total 68,000. ICD-10 codes look nothing like ICD-9 codes, and will thus involve a new learning curve for clinicians to become familiar with them.

The switch to the new coding set is scheduled to take place October 1, 2013. The main burden on physicians will be (1) learning a new coding system that will replace (and look nothing like) the long-familiar system, and (2) migrating old diagnosis codes in their EHRs to the new ones. Given that there are many more ICD-10 codes than there are ICD-9 ones, the migration mapping is challenging. It will affect EHRs, and it will affect the structure of Clinical Quality Measure queries.

But, in order that billing systems can accommodate the expanded field length for diagnoses, a new format system for electronic billing needs to take place first. The old format, referred to as the 4010 Electronic Administrative Transaction specification, was defined by HIPAA – even though we think of HIPAA as being about data privacy and security, its main thrust was defining how electronic billing should be structured, so that it is standardized across the industry.

The new version of the HIPAA transaction standards is the Version 5010. Transition to the Version 5010 begins on January 1, 2012 – just a few weeks away. This new format has been a central focus for developers of electronic billing software, who have been revamping their systems in order to produce Version 5010 output files, and receive (and adjudicate) response files (electronic Explanation of Benefits, or EOBs). This last year, from January 1 through December 31, 2011, CMS began accepting both the old 4010/4010A formats and also the 5010 formats in order to make sure everything worked properly and testing could be done. Now, with the new year, use of the 5010 version is mandatory, and the old 4010/4010A version are being dropped.

What changes are found in Version 5010?
Beyond simply expanding the diagnosis fields to accommodate anticipated ICD-10 codes (the main reason for making the change as part of the ICD-10 conversion), there are some other changes that are worth being aware of:

1. The new format allows for 12 diagnosis codes to be associated with each line item of procedure code (historically, only 4 diagnosis codes were allowed).
2. Allows for ICD-10 codes, though it will accommodate ICD-9 codes until the upcoming transition on October 1, 2013. There is a one-digit flag indicating which ICD code version is being used.
3. Standardizes (limits variability or ambiguity) the business information related to the transaction (provider identifiers).
4. Billing and Service providers will now require street addresses with 9-digit zip codes
5. Claims with an Inpatient place of service should include an Admit Date

Accompanying the HIPAA Version 5010, which is for medical services (outpatient and hospital), there is a new version of billing specifications for pharmacies too – the transition from NCPDP Version 5.1 to the new Version D.0. A new change for pharmacy billing is that claims with NDC codes (the medication identifier codes) must now be accompanied by the Quantity and Measurement. Medical providers don’t generally need to be concerned about this (unless they have and bill for dispensing pharmacies), but only should be aware that the changes are sweeping and affect most everyone across the board.

Do clinicians need to do anything now?
The imminent next step affects billing systems, not EHR systems. It is a transition that is needed prior to the transition to ICD-10 (which most certainly will affect EHR systems). Clinicians need to ensure that the billing software they use is ready to make the transition – they have been testing this all year long.

Billing systems have been tested not only to send billing messages to CMS and to insurance companies using the new 5010 version, but also to receive the new version of Electronic Remittance Advice files (the electronic EOBs) and automatically post the payments against their claims. Again, this has been tested all year long.

The main points for EHR users at this stage is simply to be aware of the transitions. ICD-10 is coming (October 1, 2013), and the impact there will be significant. Other than the few items pushed from the EHR to billing systems (such as allowing for up to 12 diagnoses per procedure), the other changes are all on the billing side. Contact your billing software vendor, or your billing service (if you outsource this) to verify that everything is on-track. It should be, at this stage.