HIPAA's administrative simplification provisions include standardized electronic transactions and code sets.  Physician practices must transition from the current version to the new version by January 1, 2012.

As providers are going to transition to the standardized electronic transactions format, they also have to upgrade from ICD-9 to ICD-10.  The effective date to the new ICD-10 is set to October 1, 2013. The best time to ensure a smooth transition is now.  As providers are purchasing new EHR systems, they need to make sure that the new ICD-10s are also loaded in the system they are purchasing.

Who is affected by the transition to ICD-10?

HIPAA-covered entities affected by the standardized electronic transition include:

• Providers, such as physicians, alternate-site providers, rehabilitation clinics and hospitals;
• Health plans;
• Healthcare clearinghouses; and
• Business associates such as billing services and vendors.

Practice management system vendors are an important part of this process, but are not HIPAA-covered entities.

What are the standardized electronic transaction changes?

• Claims
• Remittance Advice (EOBs)
• Claim status inquiry/response
• Eligibility inquiry/response

In addition to the above, Medicare will also be adopting three more electronic formats:

• Transaction acknowledgement
• Functional acknowledgement
• Claims acknowledgement

The diagnosis format change, albeit costly, is a necessary change. ICD-9 is limited and many diagnosis categories have become full, making it difficult to create new codes. Currently, ICD-10 is at 70,000 codes and has room to expand even more.

With all the changes in healthcare, one that would have the biggest impact on the providers' cash flow is going to be the transition from ICD-9 to ICD-10.

If you are a Medicare provider but do not participate with Medi-Cal, you are now eligible to be reimbursed by Medi-Cal for the cost sharing amounts. To be reimbursed, the Department of Health Care Services (DHCS) has developed a new application for this purpose. This application will NOT enroll you as a provider in Medi-Cal.

"Crossover Only" providers are those providers who are enrolled in Medicare, not enrolled in Medi-Cal, and provide services to dual-beneficiaries. Dual-eligible beneficiaries are those beneficiaries who are eligible for coverage by Medicare (either Medicare Part A, Part B or both) and Medi-Cal.

Typically, claims for services rendered to dual-eligible beneficiaries are processed by Medicare and then electronically sent to Medi-Cal for the applicable cost sharing amount.  If the claim does not cross over automatically from Medicare, an application request to bill for the claim can be submitted directly to Medi-Cal.

If you are interested to apply as a "Crossover Only" provider, MedPro can help you complete this application with a reasonable cost.