Individuals & Families Employers Brokers Physicians Health & Wellness

HIPAA 5010 and ICD-10

Timeline of Provisions

HIPAA 5010 and ICD-10

Summary

The Administrative Simplification provision of the Patient Protection and Affordable Care Act of 2010 (the Act) requires covered entities – health plans, health care clearinghouses and providers – to upgrade to new standards in electronically conducting certain administrative transactions.

Two of the key building blocks to achieve Administrative Simplification compliance are HIPAA 5010 and ICD-10. The combined changes of HIPAA 5010 and ICD-10 impact the entire payer organization.

HIPAA 5010 requirements modernize the standards that regulate electronic transactions. Upgrades primarily impact health information systems and technology and are essential to transitioning to ICD-10.

The International Classification of Diseases, 10th Edition (ICD-10) replaces ICD-9 codes and is the update of sign and symptom codes developed by the World Health Organization. Physicians and health care professionals use the codes to report diagnoses and procedures, and payers use the codes to accurately pay for procedures and services. The ICD-10 code set reflects advances in medicine and uses current medical terminology.

There is more than eight times the number of ICD-10 codes than ICD-9 codes. Under ICD-9, an angioplasty was represented by one code; under ICD-10, an angioplasty could be represented with one of 854 codes.

New ICD-10 Implementation Date

On April 1, 2014, President Obama signed into law legislation that states that the Department of Health and Human Services (HHS) cannot adopt the ICD-10 code set as the standard until at least Oct. 1, 2015. This is the second consecutive one-year delay for the ICD-10 implementation and is expected to be the last such delay.

ICD-10 refers to the International Classification of Diseases, 10th Revision developed by the World Health Organization. ICD-10 replaces ICD-9 codes used by physicians and health care professionals to record and identify diagnoses and procedures for purposes of claims payment and reporting. ICD-10 affects diagnosis and inpatient procedure coding; it does not affect CPT coding for outpatient procedures.

The transition to ICD-10 is significant and challenging for both payers and providers. The number of codes under ICD-10 will increase dramatically. In total, the number is increasing from approximately 18,000 to 140,000 codes. Over time, a number of benefits from the ICD-10 implementation will emerge: improved payment accuracy, fewer rejected claims and improved disease management.

UnitedHealthcare was on track to comply with the previous compliance date of Oct. 1, 2014.

UnitedHealthcare Readiness

UnitedHealthcare is on track to comply with both requirements by the implementation deadlines.

UnitedHealth Group is the first health care organization in the nation to complete the Committee on Operating Rules for Information Exchange® (CORE®) Phase I and II testing process using the updated 5010 platform.

UnitedHealthcare has actively engaged more than 10,000 providers across the country conducting town hall meetings to share industry-informative materials and transition plans.

Timing

Jan. 1, 2013 Eligibility and claim status operating rules compliance date.
May 6, 2013 National Provider Identifier compliance date.
Jan. 1, 2014 Electronic funds transfer and electronic remittance advice compliance date.
Nov. 5, 2014 Health Plan Identifier compliance date. For small health plans, the date is Nov. 5, 2015.
Oct. 1, 2015 ICD-10 new compliance date.

For More Information

  • ICD-10 Code Look-up Tool – Tool converts ICD-9 to ICD-10 and 1CD-10 to ICD-9 codes
  • News Release: UnitedHealth Group is First to Achieve CAQH CORE Certification – April 12, 2011 (PDF)

Frequently Asked Questions

What are the benefits to ICD-10?

Some of the advantages of transiting to ICD-10 include:

  • Decreased need to include supporting documentation with claims
  • Fewer claim rejections and denials due to non-specific diagnoses
  • Fewer requests for clinical information
  • More precise pricing structure
  • Reduced rework and administrative expense for physicians and payers

It's important to note that the benefits won't be fully realized for several years after the Oct. 1, 2014 implementation date.

What are the challenges to transitioning to ICD-10?

There are some challenges that providers and payers must overcome to see success:

  • Lack of industry-accepted crosswalk presents challenges as organizations create their own mappings.
  • Providers that are not prepared for the transition may find themselves closing or merging.
  • Significant financial investment ranging between $83,290 for a small practice to $2.7 million for a large practice.
  • Increase in denial rates and errors as health care professionals adjust to the complexity of the new system.
  • Plan design and pricing structure reconfiguration that aligns with the precise ICD-10 diagnosis codes.
  • Dual coding systems for a period of time to access both ICD-9 and ICD-10 codes. As of Oct. 1, 2014, ICD-9 codes will not be accepted.
What is the impact to employers with both of these upgrades?

After the transition to ICD-10, the amount of errors in claims processing may increase for a short time as the industry adjusts to the new coding requirement, which will increase the amount of denials employees experience.

How will the addition of more codes under ICD-10 affect reimbursement?

ICD-10 offers more specific diagnosis reporting which means:

  • Fewer claim rejections and denials due to non-specific diagnoses
  • Fewer requests for clinical information
  • More precise pricing structure
  • Greater specificity means fewer requests for supporting clinical documentations and faster reimbursements

While both HIPAA 5010 and ICD-10 transitions will positively impact the accuracy and speed of claims payments, it's important to know that the benefits will not be fully realized for several years after implementation.

What if providers are not ready by the compliance deadline?

Providers are required to comply with 5010 and ICD-10 upgrades. Under the Administrative Simplification provision requirements, ICD-9 codes used in transactions for services or discharges on or after Oct. 1, 2015, will be rejected as non-compliant and the transactions will not be processed. Providers may experience disruptions in transactions being processed and receipt of payments.

What is UnitedHealthcare doing to prepare for these upcoming changes?

UnitedHealthcare is on track to fully comply with both HIPAA 5010 and ICD-10 requirements.

  • First health care organization in the nation to complete the Committee on Operating Rules for Information Exchange® (CORE®) Phase I and II testing process using the updated 5010 platform.
  • Investing hundreds of millions in technology, training and resources as ICD codes are fundamental elements of our business
  • Engaging providers across the country conducting town hall meetings and sharing our transition plans
  • Working to ensure payment rates for services in an ICD-9 environment, equal rates in an expanded ICD-10 code set
  • Evolving our payment methodologies to support health care quality as we gain experience and data with the ICD-10 codes
  • Complying with performance guarantee requirements defined in customer contracts regarding regulatory compliance
When will UnitedHealthcare be compliant with 5010 and ICD-10?

UnitedHealthcare is on track to comply with both requirements by the implementation deadlines. UnitedHealthcare will be ICD-10 code-ready to allow for business process changes, training, contract renewals, and trading partner testing.