We all know how those year-end deadlines sneak up on us and how there never seems to be enough time to get everything done. Well, here’s some welcome news – The feds have decided to play Santa and give us a little more breathing room this season.


HIPAA 5010 Transition

CMS is transitioning its electronic transaction standards from Accredited Standards Committee (ASC) X12 version 4010A1 to ASC X12 version 5010. These standards regulate the transmission of certain health care transactions among covered entities including hospitals, physician practices, health plans and clearinghouses. Although this description may sound like impenetrable technobabble, CMS considers  the upgrade necessary to increase transaction uniformity, support pay-for-performance methods and streamline reimbursement transactions, particularly with the coming exponential expansion of diagnosis codes under ICD-10.  CMS summarizes the improvements as follows:

“Version 5010 of the HIPAA standards includes improvements in structural, front matter, technical, and data content (such as improved eligibility responses and better search options). It is more specific in requiring the data that is needed, collected, and transmitted in a transaction (such as tightened, clear situational rules, and in misunderstood areas such as corrections and reversals, refund processing, and recoupments). Further, the new claims transaction standard contains significant improvements for the reporting of clinical data, enabling the reporting of ICD–10–CM diagnosis codes and ICD–10–PCS procedure codes, and distinguishes between principal diagnosis, admitting diagnosis, external cause of injury and patient reason for visit codes. These distinctions will improve the understanding of clinical data and enable better monitoring of mortality rates for certain illnesses, outcomes for specific treatment options, and hospital length of stay for certain conditions, as well as the clinical reasons for why the patient sought hospital care.

Finally, Version 5010 also addresses a variety of currently unmet business needs, including an indicator on institutional claims for conditions that were “present on admission,” and accommodating the use of the ICD-10 code sets, which are not supported by Version 4010/4010A1.”

Level I Compliance was required by December 31, 2010, meaning that a covered entity can demonstrably create and receive compliant transactions, resulting from the compliance of all design/build activities and internal testing. Level II Compliance is due by: December 31, 2011, and all covered entities must be fully compliant on January 1, 2012. Level II compliance means that a covered entity has completed end-to-end testing with each of its trading partners, and is able to operate in production mode with the new versions of the standards.  

In a notice posted on December 14 on Medicare Learning Network as MLN Matters® Number: SE1137, CMS’ Office of E-Health Standards and Services (OESS) announced that it would not initiate enforcement with respect to any HIPAA covered entity that is not in compliance on January 1, 2012 with the Version 5010 standards until March 31, 2012. Importantly, this is only a 90-day delay on the enforcement of the transition, including fines. Claims not submitted under the 5010 standards on or after January 1, 2012 may not be paid, unless CMS has accepted a transition plan. Modern Healthcare reports that most physician practices are relying on their clearinghouses to convert claims into the new format, or assuming that an updgrade in software will meet all the new standards.

If you don’t know your practice’s status regarding 5010 compliance, contact your clearinghouse or practice management system vendor as soon as possible to avoid an unanticipated interruption in your revenue stream.

Extension of HITECH Meaningful Use Stage 2 Deadline

Physicians who met the Stage 1 Meaningful Use criteria to qualify for the HITECH Act’s subsidies in 2011 will get another year to meet the Stage 2 criteria, according to a HHS notice . Under the current requirements, eligible doctors and hospitals that begin participating in the Medicare EHR (electronic health record) Incentive Programs this year would have to meet new standards for the program in 2013. If they did not participate in the program until 2012, they could wait to meet these new standards until 2014 and still be eligible for the same incentive payment. To encourage faster adoption, HHS Secretary Sebilius announced that HHS intends to allow eligible providers to adopt health IT in 2011, without meeting the new standards until 2014. The final Stage 2 meaningful use criteria will appear in a Notice of Proposed Rulemaking scheduled to be published in February 2012.

The HHS press release also linked to a CDC survey that indicated that physician use of electronic records had doubled in the past two years. The reprt shows that in 2011, 57% of office-based physicians used EMR/EHR systems, ranging from 40% in Louisiana to 84% in North Dakota. Over half intended to apply for the HITECH incentives. In Pennsylvania, CDC reports that  50% of office-based practice use some EHR, and that 47.5% planned to apply for HITECH funds.