By now, most hospitals know of the impending 2013 implementation deadline for ICD-10. What they may not know, however, is that there is an even earlier compliance deadline necessary to make the transition possible.

January 1, 2012: This is the date by which providers must be ready to submit claims electronically using HIPAA Version 5010—an updated national code standard for billing software that replaces Version 4010 and that can accommodate the longer and more detailed ICD-10 codes. As with 4010, the new version applies to transactions with all payers—not just with fee-for-service Medicare.

Even though ICD-10 seems to be stealing the spotlight these days, the transition to 5010 will surely begin to take center stages as hospitals realize that it is a necessary prerequisite for helping to ensure a seamless transition.

Aside from being able to accommodate ICD-10, other benefits of 5010 include:

• Improvements for the reporting of administrative and clinical data


• The ability to distinguish between principal diagnosis, admitting diagnosis, external cause of injury, and patient reason for visit codes

The reasons for moving to 5010 are many, but perhaps the most important one is that delayed compliance could affect a hospital's bottom line. If hospitals don't start planning now, they could see delayed payments, or—worse yet—no payments once the compliance deadline rolls around, says Pam Matthews, CPHIMS, FHIMSS, senior director, Healthcare Information Systems for HIMSS in Atlanta.

More than 99% of Medicare Part A claims and more than 95% of Medicare Part B claims are received electronically, according to CMS. Version 5010 will enable payment for these claims to occur once the industry moves to ICD-10.

CMS released special edition Medlearn Matters article SE0904 that provides an introductory overview of HIPAA 5010 and states, "The implementation will require changes to the software, systems, and perhaps procedures that you use for billing Medicare and other payers. So it is extremely important that you are aware of these HIPAA changes and plan for their implementation."

HIPAA requires HHS to adopt standards that covered entities (e.g., health plans, healthcare clearinghouses, and certain healthcare providers) must use when they electronically conduct certain healthcare administrative transactions, such as claims, remittance, eligibility, claims status requests and responses, and others. The Transactions and Code Sets final rule published on August 17, 2000 adopted standards for the statutorily identified transactions, some of which were modified in a subsequent final rule published on February 20, 2003. The industry has been using Version 4010 for healthcare transactions since then; however, HHS announced a final rule on January 16 that requires a transition to Version 5010.

One of the most important steps a hospital can take now to ensure compliance is to initiate conversations about 5010 with billing or EMR vendors as well as larger payers. Failure to comply with the 2012 deadline could result in a major data flow disruption regardless of whether the noncompliance stems from the payer, software clearinghouse, billing vendor, or software vendor because they each play an important role in the overall payment process, Matthews says.

California soon may become the first state in the nation to set a maximum number of hours a health plan enrollee may wait before getting in to see a doctor.

Under the proposed regulations that are six years in the making, a patient needing an "urgent" appointment for a service not requiring prior authorization must be seen within 48 hours. For urgent appointments requiring prior authorization, they must be seen within 96 hours.

Patients would be allowed to speak with a doctor on the phone or receive a "triage" call back from a health professional–not answering service personnel–within 10 minutes, no matter what time of the day or night they call.

"We're trying to improve the entire system of care so that it's more responsive to the enrollees' needs," says Cindy Ehnes,  director of the California Department of Managed Health Care, which was given authority to write such regulations with a law passed in 2002.

Health plans and physicians remain opposed. But Ehnes says that for six years, their objections have been under discussion, and the proposed regulations have been re-written nearly six times. "We've been working very closely with the stakeholders to minimize their concerns," Ehnes says. Now, she says, the regulations must be set.

Ehnes says the proposed regulations must resolve the numerous complaints from health plan enrollees who "all too often, can't find a doctor who is listed as part of the network, is open, and accepting patients. Our response to this is to require health plans to have an adequate panel of physicians," both primary care practitioners as well as specialists. "That goes for rural areas as well."

According to the proposed regulations, non-urgent visits for primary care must be allowed within 10 business days of the appointment request. Non-urgent visits with specialist physicians should take place within 15 business days of the request.

And urgent visits within a dental plan network provider should occur within 72 hours of the request, while non-urgent dental visits should take place within 36 business days of the request.

The most recent version of the proposed regulations may include some modifications when the final version is released before the end of this month, Ehnes says. But she does not anticipate major changes.

"We believe we have genuinely addressed the real concerns from the physician community that they're going to have to wear stop watches, or that this will impose a situation that will potentially interfere with their clinical judgment," she says.

The new rules will apply to about 39 plans within her purview, covering about 17 million lives. Under state law, the rules must be promulgated by the end of the year or else new legislation will have to be written and passed, with the regulatory process starting all over again. Ehnes does not think that will happen.

The department has the authority to impose fines, with previous penalties up to $10 million assessed against the state's largest for-profit health insurer, Anthem Blue Cross, last year for dropping more than 1,000 patients after they became ill.  The department also can require corrective action.

The proposed regulations say penalties would be considered because of "patterns" of non-compliance rather than isolated episodes.

But health plan and physician groups say they still have concerns.

"We agree with the idea that everybody needs to see and have access to the doctors they need," says Charles Bacchi, president of the California Association of Health Plans. "But our view is that when it comes to making decisions about which patients get seen first, in a doctor's office or group practice or a clinic, it's really the doctor's call."

Besides, he says, it's unfair to hold health plans responsible for a standard that the physicians who contract with those plans must enforce.

"Throwing these new requirements into our contracts is not going to be easy. Secondly, we're the ones who will get fined," Bacchi says.

The California Medical Association in February issued a nine-page summary of its objections. A primary concern is that physicians will be blamed for something that is the health plans' responsibility.

"This will definitely add more tension between doctors and HMOs," says CMA attorney Armand Feliciano.

The physician group's concern, he says, is that historically, health plans have not had enough doctors in their plan networks, especially in rural and underserved parts of the state. "If you're going to have a time standard of 48 hours, you've already set it up for failure if you don't have enough doctors in the networks," he says.

"These requirements impose a 'stop watch' mentality. You don't want your doctor looking at you saying 'Sorry, I've got to go to the next patient.' That's not quality of care."

In the objection summary, he wrote, "In truth, the proposed regulation may have the unintended consequence of compromising current patient care. Specific time standards ... may shorten the time doctors are able to spend with individual patients, or worse, they may be forced to turn away patients just to comply."

Ehnes says the regulations do not put a stop watch on doctors. "What's the foremost concern to the department is this notion of what you might call triaging the patient," she explains. "The system must provide a way to assess the individual's condition and provide a timely response to what their needs are."

For example, she says, all too often, patients get an answering service when they call their doctor.

"It's 12:01 p.m. You call them up and say 'My daughter's really sick.' You hear that they're all at lunch. And the voice on the phone says 'We'll have someone call you back this afternoon.'"

Under the new regulations, she says, "That's no longer an acceptable response."

Anthony Wright of Health Access, an advocacy group that helped write the original 2002 bill, says that while the most egregious problems were publicized seven years ago, "we continue to hear stories of people who aren't able to see a doctor in a reasonable amount of time.

"At some level, the long waits almost become so routine, people don't know it's wrong that they can't get in to see a pediatric neurologist for two or three months."

Wright added that many studies over the years have attributed increases in emergency room visits to people who have insurance, "but who could get an appointment with their doctor in time."

A new tax on employer-provided health insurance is emerging as a likely option to finance an overhaul of the nation's healthcare system, despite opposition from organized labor and possibly the Obama administration. Details have yet to be resolved, including whether to tax the benefits of all workers regardless of income and what portion of their employer-paid insurance premiums to tax. But the idea won some acceptance during a closed-door meeting of the Senate Finance Committee.

A study published in Health Affairs adds weight to the argument that care variations lead hospitals in some parts of the country to charge Medicare far more than hospitals in other places, even when they aren't necessarily delivering higher-quality care. The study found that the variations occur not only from region to region, but also from hospital to hospital in cities around the country. The study also found hospitals that charge more fare worse on standard quality measures.