Summer 2009

HIPAA-AS electronic transactions 
and code sets are changing

On January 16, 2009, the Department of Health and Human Services announced the final rules for changes to the federally mandated Health Insurance Portability and Accountability Act-Administrative Simplification (HIPAA-AS) standard covered electronic transactions (version 5010) and new code set standards (ICD-10).

Compliance dates are January 1, 2012, for the updated electronic transactions and October 1, 2013, for the new code set standards. A transition period for implementing the new electronic transactions is scheduled to begin January 1, 2011, and end December 31, 2011.

What’s changing with HIPAA-AS 5010?

HIPAA-AS 5010 incorporates more than 500 changes (100 plus just for new claims data) to the current standard and will provide the following business values:

• Improvements to the structure of electronic transactions will increase the value of data and the rules that govern data content while enabling future capabilities.
• Changes will resolve current data ambiguities and inconsistencies across the HIPAA-AS standard covered electronic transactions.
• Changes will remove and resolve current shortcomings and increase the business value of the HIPAA-AS standard covered electronic transactions.

What’s changing with HIPAA-AS ICD-10 
(International Classification of Diseases, 10th Edition)?

ICD-10-CM (Clinical Modification) and ICD-10-PCS (Procedure Coding System) are new medical code sets under HIPAA-AS for diagnosis reporting and represent a fundamental overhaul of the current ICD-9 (International Classification of Diseases, 9th Edition) coding system:

• ICD-10-CM replaces ICD-9-CM
• ICD-10-PCS replaces CPT-4 (Current Procedural Terminology, 4th Edition) and HCPCS (Health Care Common Procedure Coding System) for ONLY inpatient hospital procedure coding

Current ICD-9 code sets (17,000) are outdated and do not reflect advances in medical technologies nor are they descriptive enough. The new ICD-10-CM and ICD-10-PCS code sets will:

• Provide greater flexibility to enable future capabilities and allow for more than 155,000 codes.
• Contain more descriptive and robust categories for precise coding, streamlined reimbursement processes and richer data quality for further analysis.
• Maximize the value of clinical data and the business value of interoperability of e-health initiatives and electronic health records.

Implementation of HIPAA-AS 5010 and ICD-10 are intended to improve patient care quality, enhance claim processing, improve data reporting and promote increased interoperability across industry stakeholders. Significant impacts to provider billing and payment processing will be realized across the health care industry if stakeholders fail to collaborate, coordinate and communicate throughout this transition.