Let’s Not Forget About 5010/D.0/3.0

By Angela “Annie” Boynton RHIT, CPC, CCS, CPC-H, CCS-P, CPC-P, CPC-I

All of those involved in the health care industry are working in a revolutionary time, an exciting time and a stressful time!  Current workers will see a major code set change and see our country overhaul its health care infrastructure in order to support a nationwide electronic health record environment.  With ICD-10 taking over so much of the limelight recently, it is easy to overlook some of the vitally significant steps along the way.  Equally important, but much less famous, is the conversion to the ASC X12 version 5010 architecture, more commonly known as 5010, and the NCPDP versions D.0 and 3.0.

Currently HIPAA mandates that electronic data interchange (EDI) transactions are conducted in the current ASC X12 versions 4010A1.  However, this version has become outdated, especially in light of the coming ICD-10 migration.  Covered transactions as defined by HIPAA include status checks, administrative transactions, remittance, eligibility inquiries and responses.  All HIPAA covered entities that use electronic data interchange will be responsible for transitioning to 5010, which includes providers, payers and health care clearinghouses.  5010 represents more than a simple system change; rather it is a whole new language in which to process EDI transactions.

The transition to 5010 is a vital step in the path to successful ICD-10 implementation.  The 5010 architecture increases the field size for diagnostic codes to accommodate the longer ICD-10 code structure.  Simply put, if 5010 fails, ICD-10 will fail.  With a firm deadline for ICD-10 implementation in place by CMS, 5010 migration cannot fail.  There are benefits to be had by the 5010 conversion. For example, 5010 will allow for more diagnostic codes to be included on claims and will enable clear distinction between the ICD-9 and ICD-10 code sets.  However it is important to understand that the 5010 transition will not in any way aid in the overall transition to ICD-10.  It will facilitate the use of ICD-10 codes in the electronic environment, but ICD-10 will need to be implemented as mandated.

Recently CMS announced that along with 5010 conversion, the National Council for Prescription Drug Programs (NCPDP) versions currently in use for both retail pharmacy and Medicaid pharmacy will upgrade to D.0 and 3.0, respectively.  Like the updates to 5010 and ICD-10, the D.0/3.0 upgrade will accommodate changing business needs and will also bring the respective system into alignment with Medicare part D requirements as set forth by the MMA.  The D.0 conversion most heavily impacts retail pharmacy, while the 3.0 deals directly with Medicaid subrogation and will provide a standardized method of recouping inappropriate Medicaid payments.  This is good news in our current health care economy.

The 5010/D.0/3.0 implementation deadline as set forth by CMS is January 1, 2012, with recommendations that internal testing begin on or after January 1, 2010, and external testing begin on or after January 1, 2011.  CMS recommends the development phase begin January 1, 2009.  Many covered entities have not even thought about ICD-10 yet alone 5010/D.0/3.0.  Waiting for industry changes or rule changes is not going to make this go away.  The key to the successful migration to 5010/D.0/3.0 is to begin now.

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