Confluencing HIPAA 5010 and ICD-10 – How to tie the Two Developing Silos

When HIPAA Administrative Simplification Compliance Act was signed back very early in the decade, no one in the industry could predict that the transactional requirements would be this granular – I mean to the level of Diagnosis code and the Procedure code. Truly it gives us a tremendous sense of maturation across the board – all entities that are active participants in the HIPAAI (4010A1) and now HIPAAII (5010).

But at the same time, all covered entities are severely burdened with two compliance requirements, enablement of which is a mandatory requirement. ICD-10 deployment is only technically feasible after one achieves HIPAA 5010 governance requirements. The requirements are stringent, and to top it all it is a moving target.

Just to cite an example as to how HIPAA rules are constantly being re-defined – on Wednesday, October 13, 2010, the Department of Health and Human Services (HHS) published in the Federal Register, a notification announcing maintenance changes to the standards. All covered and non-covered entities now have no option other than downloading all these Errata documents from ASC X12 website and implement all the changes that are prescribed in these documents.

This is going to be even harder for all players given that the Level I compliance must be achieved by December 31, 2010. According to CMS, Level I compliance means "a covered entity can demonstrably create and receive compliant transactions, resulting from the compliance of all design/build activities and internal testing."

The major challenge is to be 5010 compliant and then move on to ICD-10 implementation in the next 22 months (January 2012-October 2013). After which ICD-10 will be the only way to trade Diagnosis and Procedure codes in relevant healthcare transactions.

Life would be simpler if the Claim-Eligibility-Authorization-Payment transactions’ transceivers would be limited to populate and receive the ICD-10-CM and ICD-10-PCS for the Diagnosis and the Procedure code(s) respectively. Instead, there are such things called Revenue Cycle, Fee Schedules, Reimbursement Mapping, Bundling-Unbundling-Splitting Claims, Reason codes (CARC) and Remark codes (RARC), etc. It is yet to be seen how the major players intend to integrate all these pieces together.

Notwithstanding, a balancing strike needs to happen to make both the HHS requirements an achievable reality. These two silos must be connected to each other. The RoI is expected to be in the range of $700 million to $7.7 billion just for implementing ICD-10. From CMS enabling the agency to catch the medicare and medicaid defrauders to Homeland Security enabling to signal bio-terrorism at the earliest – the benefits of compliance are many.

In the near future, will be to discussing how to tie the two: 5010 and ICD-10 projects with regard to resolving the resultant destination code from the Claims data source information. Eventually, it is this synthesis of the transactional information that typically reside on the 837 Claim/other transactions (including but not limited to requested Diagnosis codes and Procedure codes) and already "resident" clinical information on the General Equivalency Mappings/other Crosswalks.

We predict that one-for-one numerical relationship between ICD-9-CM (Volume 3) to that of ICD-10-PCS, will be harder to resolve due to certain parametric conditions such as specificity, laterality, etc. when chronological relevance of the episodic occurrence is also examined, found in Diagnosis codes requested on the same transaction.

Harder as it might be, payers must pay within the given contractual time frame and providers must achieve the revenue flow and it is this sustainability issue that will be a hot topic area in this ICD migration process.

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Confluencing HIPAA 5010

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