CMS Issues Final Administrative Simplification Final Rules Regarding Identifiers and ICD-10 Code Set Compliance Delay

August 24, 2012.  Today, the Office of Management and Budget (OMB) completed review and sent to the Federal Register for publication on September 5, 2012, the Centers for Medicare & Medicaid Services (CMS) Final Rule:  Administrative Simplification:  Adoption of a Standard for a Unique Health Plan Identifier; Addition to the National Provider Identifier Requirements; and a Change to the Compliance Date for the International Classification of Diseases, 10th Edition (ICD-10-CM and ICD-10-PCS) Medical Data Code Sets.  The effective date of the Rule is November 5, 2012.  Prior to publication, the Final Rule may be examined at or downloaded from the Office of the Federal Register’s Electronic Public Inspection Desk.

Here is the Executive Summary from the Final Rule:

“This rule adopts a standard unique health plan identifier (HPID) and a data element that will serve as an other entity identifier (OEID).  This rule also adopts an addition to the National Provider Identifier (NPI) requirements.  Finally, this rule changes a compliance date for the ICD-10-CM and ICD-10-PCS medical data code sets (hereinafter ‘code sets’) from October 1, 2013 to October 1, 2014.

(1) HPID.  Currently, health plans and other entities that perform health plan functions, such as third party administrators and clearinghouses, are identified in Health Insurance and Portability and Accountability Act of 1996 (HIPAA) standard transactions with multiple identifiers that differ in length and format.  Covered health care providers are frustrated by various problems associated with the lack of a standard identifier, such as: improper routing of transactions; rejected transactions due to insurance identification errors; difficulty in determining patient eligibility; and challenges resulting from errors in identifying the correct health plan during claims processing.

“The adoption of the HPID and the OEID will increase standardization with HIPAA standard transactions and provide a platform for other regulatory and industry initiatives. Their adoption will allow for a higher level of automation for health care provider offices, particularly for provider processing of billing and insurance related tasks, eligibility responses from health plans, and remittance advice that describes health care claim payments. [Health plans with the exception of small health plans must obtain an HPID by November 5, 2014.  Small health plans must obtain an HPID by November 5, 2015. Covered entities must use HPIDs in the standard transactions on or after November 7, 2016.]

(2) NPI.  In the January 23, 2004 Federal Register (69 FR 3434), the U.S. Department of Health and Human Services (HHS) published a final rule establishing the standard for a unique health identifier for health care providers for use in the health care system and adopting the National Provider Identifier (NPI) as that standard (‘2004 NPI final rule’). The rule also established the implementation specifications for obtaining and using the NPI.  Since that time, pharmacies have encountered situations where they need to include the NPI of a prescribing health care provider in a pharmacy claim, but where the prescribing health care provider has been a noncovered health care provider who did not have an NPI because he or she was not required to obtain one.  This situation has become particularly problematic in the Medicare Part D program.  The addition to the NPI requirements addresses this issue.  [An organization covered health care provider must comply by May 6, 2013 with the implementation specifications in 45 CFR 162.410(b), as shown on page 202 of the final rule version referenced above.]

(3) ICD-10-CM and ICD-10-PCS Code Sets.  In the January 16, 2009 Federal Register (74 FR 3328), HHS published a final rule in which the Secretary of of HHS (‘the Secretary’) adopted the ICD-10-CM and ICD-10-PCS (‘ICD-10′) code sets as the HIPAA standards to replace the previously adopted International Classification of Diseases, 9th Revision, Clinical Modification, Volumes 1 and 2 (diagnoses), and 3 (procedures) including the Official ICD-9-CM Guidelines for Coding and Reporting. The compliance date set by the final rule was October 1, 2013.

“Since that time, some provider groups have expressed strong concern about their ability to meet the October 1, 2013 compliance date and the serious claims payment issues that might ensue if they do not meet the date.  Some providers’ concerns about being able to meet the ICD-10 compliance date are based, in part, on difficulties they had meeting the compliance deadline for the adopted Associated Standard Committee’s (‘ASC’) X12 Version 5010 standards (‘Version 5010’) for electronic health care transactions. Compliance with Version 5010 and ICD-10 by all covered entities is essential to a smooth transition to the updated medical data code sets, as the failure of any one industry segment to achieve compliance would negatively affect all other industry segments and result in returned claims and provider payment delays.  We believe the change in the compliance date for ICD-10 [to October 1, 2014] gives health care providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition by all covered entities.”

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