5010: The Logical Transition for ICD-10

Although 5010 gets much less notoriety than ICD-10 it is just as important and practices should already be working with vendors on the transition to 5010. Here are some important dates to be aware of:

  • January 1, 2011 Level I compliance—ability to process 5010 transactions for testing and transition with able trading partners
  • January 1, 2012 Level II compliance—all covered entities must begin using 5010 transactions

Simply put, transactions are electronics exchanges involving the transfer of health care information between two parties for specific purposes, such as a health care provider submitting medical claims to a health plan for payment. The Health Insurance Portability & Accountability Act of 1996 (HIPAA) named certain types of organizations as covered entities, including health plans, health care clearinghouses and certain health care providers. HIPAA also adopted certain standard transactions for Electronic Data Interchange (EDI) for the transmission of health care data. These transactions include:

  • claims and encounter information
  • payment and remittance advice
  • claims status
  • eligibility
  • enrollment and disenrollment
  • referrals and authorizations

Unlike the current 4010 transaction set, 5010 is much more specific in the type of data it collects and transmits over the course of a transaction. 5010 also has clear situational rules built in which will help enhance the understanding of claim corrections, reversals, recoupment of payments and the processing of refunds.

For example, 5010 will increase the diagnostic field size to accommodate the increased size of ICD-10 codes. Some other changes include:

  • a version indicator that distinguishes between ICD-9 and ICD-10 codes
  • format changes that will increase the number of diagnosis codes allowed on a claim

Interestingly, the 5010 format does not require the use of ICD-10 codes. However, it will be able to recognize and distinguish between the ICD-9 and ICD-10 code sets, which may help with dilemmas of billing utilizing the dual code sets.

It’s important that you begin to prepare early for the transition by working with your vendors. There are many changes in store and strategic preparation is necessary. Ask your vendors what they are doing to migrate to 5010 and also what plans they have in place for testing. If your vendor is unable to offer you solutions at this time you should begin looking for a new vendor.


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