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“TMA’s role in HIPAA 5010 is to provide resources for physicians to ensure they don’t get caught in what could potentially be a regulatory nightmare. It’s essential physicians prepare for the switch to the new transaction standards for electronic claims.”


If you want to be paid for providing medical care next year, read on.


Jan. 1, 2012, marks a major change in the way practice man- agement and electronic health record (EHR) systems send and receive electronically transmitted health information, such as claims. Medicare, Medicaid, and the commercial insurance companies will stop paying physicians and other “covered enti- ties” that do not comply with Health Insurance Portability and Accountability Act (HIPAA) 5010 electronic claims standards by Jan. 1. TMA President C. Bruce Malone, MD, says HIPAA 5010 rep-


resents a “new wave of regulations in medical practice.” “TMA’s role in HIPAA 5010 is to provide resources for physi- cians to ensure they don’t get caught in what could potentially be a regulatory nightmare. It’s essential physicians prepare for the switch to the new transaction standards for electronic claims,” Dr. Malone said. Covered entities include physicians, clearinghouses, insur- ers, and others with access to digital personal health data. Workers’ compensation programs are not covered entities un- der HIPAA. Also, practices with fewer than 10 employees that don’t currently submit claims electronically don’t have to com- ply. If you’re unsure whether you’re a covered entity, consult the online chart, www.cms.gov/HIPAAGenInfo/downloads/ CoveredEntityCharts.pdf, developed by the Centers for Medi- care and Medicaid Services (CMS). Compliance with HIPAA 5010 does not apply solely to prac- tices with EHR systems. It applies to claims submitted through practice manage- ment systems. All claims sent elec- tronically, whether through a clearing- house or directly to a payer, must use the 5010 transac- tion standards. Alexis Wiesen- thal, MD, a San An-


C. Bruce Malone, MD Todd Moore, MD 12 TEXAS MEDICINE November 2011


tonio internist, started preparing for the transition to Version 5010 when her two-physician practice adopted an EHR in April. Her strategy for successful 5010 implementation is to delegate and supervise. Dr. Wiesenthal has practiced for the past three years with her father, Martin Wiesenthal, MD. They appointed one of their 20 employees to oversee the practice’s HIPAA 5010 conversion. “Avoiding an interruption in cash flow during the transition is vital to medical practices. I think it’s important to identify a project leader early on because there are so many details that need to be organized in the 5010 implementation. Physi- cians need to communicate with the project leader to ensure that person is monitoring the transactions and addressing any problems that surface,” she said. Dr. Wiesenthal realizes implementing HIPAA 5010 is neces-


sary for the financial viability of her practice, which accepts Medicare and Medicaid and contracts with 15 private insurers. The decision to select an employee to oversee the HIPAA 5010 transition is keeping the practice on schedule to meet the Jan. 1 deadline.


“She developed a plan and is working directly with vendors


to determine what we need to do to comply. She has kept us organized with the payers, clearinghouses, and vendors,” she said.


The implications of HIPAA 5010 span beyond 2012. ICD-10


will replace ICD-9 on Oct. 1, 2013, and physicians must con- vert to HIPAA Version 5010 software standards to use the new coding system in electronic transactions. The switch to ICD-10 involves updated codes and transactions standards that will cover electronic claims, insurance eligibility verification, claim status inquiries, requests for authorization, and electronic re- mittance data.


Physicians can stay abreast of TMA’s educational programs by contacting Heather Bettridge, TMA practice management consultant. Ms. Bettridge is a certified professional medical coder and has advanced training as a professional medical au- ditor. She is maintaining a database of physicians who wish to be notified of TMA’s upcoming workshops, seminars, and


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