United States Department of Veterans Affairs


On January 16, 2009, the Department of Health and Human Services published final rules that adopted updated versions of the Health Insurance Portability and Accountability Act (HIPAA) standards for electronic transactions, a new electronic transaction standard for Medicaid pharmacy subrogation and two modifications to the medical code set standards to adopt the International Classification of Diseases, 10th Revision, ICD-10-CM and ICD-10-PCS. The HAC will be working toward implementation of these changes by the compliance dates noted below. Please be sure to check with your software vendor to make sure that you are on track to upgrade your system to accommodate these changes.

For more information on the final rules, please visit Transactions and Code Sets Regulations at the Centers for Medicare and Medicaid Services (CMS) Web site.

Medical and Dental Claims
The ASC X12N standards for electronic transactions will change from Version 4010A1 to Version 5010 on January 1, 2012. These include 837 Health Care Claims (institutional, professional and dental), 835 Health Care Claim Payment/Advice, 270/271 Health Care Eligibility Benefit Inquiry and Response, 276/277 Health Care Claim Status Request and Response and the 278 Health Care Services Review Request for Review and Response.

Pharmacy Claims
The National Council for Prescription Drug Programs Telecommunications Standards will change from Version 5.1 (Batch Version 1.1) to Version D.0 (Batch Version 1.2), along with the adoption of a new standard for Pharmacy Medicaid Subrogation, Version 3.0, on January 1, 2012. For information regarding these pharmacy electronic standards changes, please visit D.0 Resources located at the CMS Web site.

ICD-10 Coding System
This final rule adopts modifications to the original ICD-9 CM and ICD-9 PCS code sets and replaces them with the International Classification of Diseases, 10th Revision, Clinical Modifications (ICD-10 CM), for diagnosis coding and the Procedural Coding System (ICD-10 PCS), for inpatient hospital procedure coding. This change, slated for compliance on October 1, 2013, will drastically alter how providers code electronic and paper health care claims. For more information about ICD-10, please visit ICD-10 Implementation on the CMS Web site.

Here are tips for avoiding seven common pitfalls in claims processing.