Physicians Win 3-Month Reprieve on Version 5010 Standards

November 17, 2011

November 17, 2011 — In a spirit of holiday-season leniency, the Centers for Medicare and Medicaid Services (CMS) announced today that it is giving healthcare providers, private insurers, and go-between companies until March 31 — or 3 more months — to switch to a new set of standards for electronic claims.

January 1 remains the official deadline for the changeover to the so-called Version 5010 standards, which also apply to other electronic billing transactions (such as requests for patient eligibility and claims status). However, the CMS department responsible for enforcing the use of the new standards will wait until March 31 to begin its policing.

At stake for physicians is their ability to get paid. Once the new standards kick in, any electronic claims based on the previous standards are supposed to be rejected.

Version 5010 is shorthand for a set of rules governing how computers exchange healthcare billing data with each other. The standards are complements of the Health Insurance Portability and Accountability Act (HIPAA), a law that aims to put the entire healthcare industry on the same digital page. All "covered entities" under HIPAA — which include claims clearinghouses as well as physicians, hospitals, and insurers — must switch their billing software from the current set of HIPAA transaction standards to the new set. Only Version 5010 will allow the use of new International Classification of Diseases, 10th revision, diagnostic and inpatient procedure codes, which become mandatory on October 1, 2013.

The Office of E-Health Standards and Services (OESS) in CMS stated in a press release that it is pushing back the enforcement date for Version 5010 because physicians, insurers, and other covered entities need more time to test software systems that have been updated to Version 5010. In addition, many covered entities are still waiting for software upgrades.

Physicians who have yet to convert over to Version 5010 should resist the temptation to procrastinate during the 3-month grace period. As of January 1, OESS will begin to accept complaints — assuming any are made — about covered entities that are not complying with the latest HIPAA standards. Any organization called on the carpet by OESS must prove that it is complying or making a good-faith effort to do so.

Medical practices seeking guidance on the Version 5010 standards can find it on the Web sites of CMS and the American Medical Association.


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