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Young Ophthalmologists
Get Hip to HIPAA 5010: What It Is and What You Need to Know
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As federal regulations push the health care industry toward e-medicine, an important change is scheduled for Jan. 1. That’s the date all practices must begin submitting claims by HIPAA 5010 standards, instead of the HIPAA 4010 standards now in use.

The bad news: As of Jan. 1, any and all non-compliant claims will be rejected (with the exception of Workers Comp) and practices won’t get paid. The good news is that, unless you’re a very small practice or solo practitioner, most of the transition process will be handled by various practice vendors and IT staff.

Why the Switch?
American Medical News reports that the new claims standards serve two purposes:
  1. To ultimately improve the efficiency of the claims process, while increasing the specificity of data capture, and
  2. To pave the way for adoption of ICD-10, a new code system coming in 2013. The HIPAA 4010 claim standards don’t support ICD-10 codes.
What Does This Mean For You?
Your involvement in the actual switch will depend largely upon the size of your practice.

Medium to large practices: Check with the vendors you use for practice management and electronic health record (EHR) support. Make sure they’re on top of the necessary upgrades and testing. Your practice may also need to update certain templates and train staff on the changes in particular claim fields. Depending on your role in a larger practice, HIPAA 5010 may have a relatively minimal impact on you, personally.

Small or solo practices: Expect to take a more hands-on role. Preparing for the transition is a multi-step process that the AMA estimates will take several months to complete.

The main steps of the process, according to the AMA, are as follows:

  1. Assess the impact of the change on your practice. Refer to for more on this analysis.
  2. Contact practice management, EHR and other affected vendors (e.g., health insurance payers, billing services). The Academy HIPAA 5010 page (above) has more information, but CMS also has a guide to talking to your vendors.
  3. Install needed upgrades (vendors and/or IT staff or consultants should handle most of this).
  4. Test the upgrades. The first stage of testing will probably be internal, but your practice should also take advantage of the various national test days CMS is conducting. The next national 5010 testing period is all this week, Aug. 22 to Aug. 26. Consult for more information on the most typical errors identified during the last national testing day.
  5. Train staff as needed.
  6. Make the switch. While the deadline is Jan. 1, you can switch to 5010 sooner if your practice is ready.
What If You Haven’t Started?
As daunting as the transition process may be, the longer you delay, the worse the possible payment implications for your practice. Start by reviewing the Academy and AMA resources listed below — particularly the AMA 5010 toolkit, which is designed to help solo practitioners or small practices that may have fewer internal resources for the transition.

In addition, your practice may need to prepare for an early January delay in payments. The American Academy of Ophthalmic Executives (AAOE) maintains a consultants directory of experts with ophthalmology-specific experience. Consultants’ expertise includes financial management. If you are attending the Annual Meeting in Orlando, you can also schedule a free, 20-minute consultation with an expert in the AAOE section of the Academy Resource Center, Booth 1359. Make an appointment in advance or during the meeting.

Getting Help?
The Academy HIPAA 5010 page provides a good overview, but the AMA and CMS also offer a host of resources:
The Academy will also continue to provide information on HIPAA 5010 and other regulatory deadlines and transaction standards that could jeopardize almost all of your practice’s third-party payments.

Note for Residents
HIPAA 5010 may have less direct effect on you, but now is still a great time to begin your practice management education. As a resident, you qualify for a free membership in the American Academy of Ophthalmic Executives, which is the Academy’s practice management arm. Free membership extends through your first year in practice.

Applying costs you nothing and gives you access to a host of valuable resources, a number of which are specifically tailored to the young ophthalmologist. You also qualify for a discount on AAOE special events at the Annual Meeting in Orlando (many AAOE courses are included in the Academy Course Pass, which is discounted to $100 for members in training).

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About the author: Christi A. Foist is the managing editor for YO Info and the Web and member communications editor for the Academy.

Academy members: login to read or make comments on this article.