Sometimes I Wish Something Could Just Stay the Same

Version 5010 Transition for Electronic Claims Submission

With almost 100 percent of Medicare Part A claim transactions being submitted electronically (and just over 96 percent of the Part B claims) using the Version 4010/4010A1 of healthcare standards, payers and providers must implement, test and transition to the 5010 Version transaction to be compliant with HIPAA no later than January 1, 2012.
You may wonder when you read "Version 5010" how this applies to you and your facility, or you may already be internally testing. There is a lot of chatter out there right now about Version 5010, so read on to find the compliance timeline table. Several FAQs are presented below on this big change impacting not only the healthcare industry but by everyone covered by HIPAA.

Table 1: Compliance Timeline for Version 5010 and ICD-10

Compliance Step
January 1, 2010
  • Payers and providers should begin internal testing of Version 5010 standards for electronic claims
December 31, 2010
Internal testing of Version 5010 must be complete to achieve Level I Version 5010 compliance
January 1, 2011
  • Payers and providers should begin external testing of Version 5010 for electronic claims
  • CMS begins accepting Version 5010 claims
  • Version 4010 claims continue to be accepted
December 31, 2011
External testing of Version 5010 for electronic claims must be complete to achieve Level II Version 5010 compliance
January 1, 2012
  • All electronic claims must use Version 5010
  • Version 4010 claims are no longer accepted
October 1, 2013
  • Claims for services provided on or after this date must use ICD-10 codes for medical diagnosis and inpatient procedures
  • CPT codes will continue to be used for outpatient services
There are four formats that are HIPAA mandated and another three not mandated by HIPAA but adopted by Medicare Fee-for-Service (FFS). These are found in Table 2 below:

Table 2: Formats and Transactions Being Changed

Formats Mandated by HIPAA
Not-Mandated by HIPAA but Medicare FSS
Claims (837-1, 837-P, 837-1 COB, 837-P COB and NCPDP)
Transaction Acknowledgement (TAI)
Remittance Advice (835)
Functional Acknowledgement (999)
Claim Status Inquiry/Response (276/277)
Claims Acknowledgement (277CA)
Eligibility Inquiry/Response (270/271)(270/271)

FAQ 1: What is Version 5010?

Answer: Accredited Standards Committee (ASC) X12 Version 5010 for electronic health care transactions

FAQ 2: What are the benefits of 5010 over the current 4010/4010A1?

Answer: Version 5010 has functionality toaccommodate the ICD-10 codes, and can handle eligibility queries and remittance advices. Version 5010 must be in place (software installed) with staff trained, internally and externally testing, new policies and procedures written, manuals and user guidelines updated prior to January 1, 2012.
Once up and running, you will see the following changes:
  1. The field size for ICD codes will increase to 7 bytes
  2. A digit will be added to indicate ICD-10 rather than ICD-9
  3. Additional number of diagnosis codes will be allowed on a claim
  4. Additional data modification in the standards adopted by Medicare FFS will happen
  5. Standardizes the business information
  6. Utilizes Technical Reports Type 3 (TR3) that represents data consistently
  7. More specific in defining the data to be collected and transmitted
  8. Distinguishes between principal and admitting diagnosis, external cause of injury and patient reason for visit codes, and "present on admission" conditions
  9. Supports monitoring of mortality, outcomes, length of stays and clinical reasons for care

FAQ 3: Who is affected by the transition to Version 5010?

Answer: All health plans, health providers and health care clearinghouses – physicians, hospitals, rehabs, clinics, etc. Also affected will be vendors and billing/service agents. Pharmacies use the National Council for Prescription Drug Programs (NCPDP) Version 5.1 which will be changed to NCPDP Versions D.0 and 3.0 which will accommodate the changes for them. So to answer who is affected, everyone who submits a claim, receives claims, or communicates claims status, inquiries and responses PLUS their IT systems.
The information presented in this article can be found on CMS's website. Go to and select "Medicare" on the home page, then select "ICD-10" and find extensive resources on the details of ICD-10 and Version 5010 in the left hand column and on, select "Education" and "CMS Resources."
Betty Hatten is a manager in health care services at HORNE LLP. Her primary responsibilities include oversight of the chargemaster assessment and maintenance team, as well as providing charge capture audits, performance improvement assessments, and focused compliance reviews. Betty is a frequent seminar presenter and customizes presentations for clients, hospital associations, and professional organizations on the local, regional, and national level.

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