HIPAA Transition from 4010A to 5010 – Part 1 of 3

What is HIPAA?
HIPAA, which stands for the American Health Insurance Portability and Accountability Act of 1996, is a set of rules to be followed by doctors, hospitals and other health care providers. HIPAA took effect on April 14, 2006. HIPAA helps ensure that all medical records, medical billing, and patient accounts meet certain consistent standards with regard to documentation, handling and privacy.

In addition, HIPAA requires that all patients be able access their own medical records, correct errors or omissions, and be informed how personal information is shared used. Other provisions involve notification of privacy procedures to the patient. HIPAA provisions have led in many cases to extensive overhauling with regard to medical records and billing systems.

HIPAA Mandated Transactions
Before anyone can switch to ICD-10, industry must upgrade all ten HIPAA transactions to a new version (version 5010) because the current version (4010) will not work with ICD-10. This is a major upgrade, a “re-architecture of the HIPAA standards.” Industry needs version 5010 not only to handle ICD-10 codes, but also because the current transaction standards are increasingly out of date. The 4010 version standards were developed in 1998, and the implementation guides that were initially adopted for HIPAA were written in 2000. Over the last 8 years, the Accredited Standards Committee X12 has made numerous changes to the original transaction standards that have not yet been made available to the industry via adoption under HIPAA. 

A copy of the final rule for HIPAA transactions, also released on January 16, 2009, can be found here. The effective date for this transition is January 1, 2012 and for small Health Plans (fewer than 50 participants), the effective date is January 1, 2013. There is no contingency plan. These are hard dates and must be met in order to meet the October 1, 2013 date for ICD-10 conversion.

About HCIM

Since 2000, HealthCare Information Management, Inc. (HCIM) has delivered expert consulting services and robotic automation tools for small to mid-sized healthcare payer and managed care organizations. Our concierge consulting services include everything from core claims system procurement to go live, including configuration, migration, upgrades, reporting, benefits and fee schedules, user training, and project resourcing. We also offer strategic consulting in the areas of value based payments, population health, medical management, medical loss analysis and recovery, care management, provider contract modeling, data analytics, and business process reengineering/analysis.