HIPPA 5010 Compliance

HIPAA 5010, or 5010 for short, refers to the new file format standard for electronic data interchange (EDI) transactions that are submitted and received by providers, health plans, and plan employer groups. Among other things, EDI transactions are used throughout the patient revenue cycle including the patient scheduling, pre-registration, registration, admission, billing, accounts receivables, and collections processes.

5010 is the foundation for future changes affecting the US healthcare industry; not the least of which is the migration to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for diagnosis coding, and the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) for inpatient hospital procedure coding. ICD-10 codes are currently used by nearly every modern nation with the United States being among the last holdouts. By making this migration, the United State will be able to better evaluate the quality and effectiveness of healthcare against that provided by other nations and leverage what the international community has already experienced.

Making this transition requires that we re-think many of our processes, including the type of information collected and how it is shared among certain types of healthcare systems. The existing 4010A1 format is being replaced to accommodate the longer, alpha numeric ICD-10 codes and the additional information that will be collected and transmitted in order to process health claims.

In most cases, software vendors are responsible for updating their software systems through product updates or possibly product replacement. For those organizations that have developed your own systems, you will be responsible for completing the required changes within the required timeframe. Regardless of who is responsible for updating the format, you are ultimately responsible to ensure that these modifications do not adversely affect your organizations revenue stream.

Celera Group provides services designed to minimize your exposure and eliminate operational risks after the compliance date. These services include 5010 Readiness Assessments, 5010 Conversion Project Management, and 5010 Remediation.

  • 5010 Readiness Assessments – are intended to provide your organizations with management information from which decisions can be made. Celera Group assessments are generally accomplished in 2 – 4 weeks, depending on the complexity of your organization. Assessment deliverables include a documented evaluation of your organizations conversion needs, systems affected by the 5010 conversion, your organizations resource readiness to take on this project, a preliminary budget, and a risk assessment that identifies your greatest areas of exposure.
  • 5010 Conversion Project Management – ARRA/HITECH include a number of initiatives that affect your organization and that must be considered as a whole when planning and implementing solutions. Celera Group consultants understand the ARRA/HITECH requirements, timelines, and process for ensuring all required tasks are completed as required.
  • 5010 Remediation – After the affected systems are identified, action must be taken to complete the conversion activities, test the interfaces, and validate the results. Celera Group can work with your vendors and/or developers to complete and test the interface changes. Celera Groups revenue cycle team will also work with your business office to reconcile claims transactions

ICD-10 Migration

ICD-10 migration affects both the financial and clinical sides of the house. On the clinical side, medical coding drives clinical outcomes, quality indicators, patient education, and more. From a financial perspective, the healthcare revenue cycle depends upon the medical coding to determine reimbursement based on plan contracts. Getting from care delivery to the point at which payment is received consists of many steps that must work together to reduce the risk of delays or non-payment. Step 1 begins with the proper coding of the procedures performed.

According to a study conducted by Deloitte Center for Health Solutions1, the “ICD-10 implementation has the potential to be so invasive that it could touch nearly all operational systems and procedures of the core payor administration process and the provider revenue cycle.” (2009). The result is an initiative that far exceeds the complexity and scope of Y2K.

Preparing for this initiative requires immediate action, beginning with an assessment of the current state from which a plan of action that drives your efforts can be developed. Celera Group consultants are ready to help you evaluate the impact of ICD-10 to your organization and help you plan for the migration.

Meaningful Use

When most people think of ARRA and its requirements, the term “meaningful use” immediately comes to mind. But what is meaningful use? How will the meaningful use requirements affect your organization? What are the advantages of getting to meaningful use sooner than later and what happens if you fail to accomplish meaningful use as required? These are all questions that Celera Group consultants can address so you can get underway to meet compliance.

The compliance requirements for Meaningful use are evolving over the next few years with MU being implemented in stages. Stage 1 Meaningful Use rules are defined and consists of over 20 specific requirements that must be attained in order to be considered compliant. With an emphasis on the delivery of quality, safe, and effective care, MU requirements include, among many other requirements, sharing clinical data with others through an information exchange.

Getting to meaningful use impacts most every aspect of the providers workflow and requires the use of a certified electronic health record for placing orders, prescribing medication, determining drug/drug interactions and allergies, documenting patient demographics and so much more.

Once again, Celera Group can help. Using a meaningful use assessment tool to evaluate your organizations processes and technology against the requirements, Celera Group can deliver a comprehensive analysis of where you are today and where you will need to concentrate to meet the meaningful use requirements within the stated deadlines.

1Turning Regulatory Compliance into Strategic Advantage. (2009). Deloitte Center for Health Solutions.