CMS Issues Deadlines for Providers Compliance with Version 5010 Standards
The Centers for Medicare & Medicaid Services (CMS) has issued a reminder to healthcare providers, health plans, clearinghouses, and vendors about the approaching compliance dates for a new generation of diagnosis and procedure codes and updated standards for electronic healthcare transactions.
Beginning in January 2011, entities covered under the Health Insurance Portability and Accountability Act (HIPAA) should be ready to test with their trading partners the functionality of the entities’ practice management and/or other related software featuring Version 5010 standards. Use of the Version 5010 standards for HIPAA electronic healthcare transactions—including claims, remittance advice, eligibility inquiries, and referral authorizations—will be mandatory on Jan. 1, 2012. The Version 5010 standards also provide the framework needed to use the revised medical data code sets (ICD-10-CM and ICD-10-PCS) that must be implemented on Oct. 1, 2013.
A fact sheet describing the two regulations governing the ICD-10 code set and Version 5010 electronic transaction standards is available on the CMS website.
CMS Record Retention & Privacy Guidelines
State laws generally govern how long medical records are to be retained.
However, the Health Insurance Portability and Accountability Act (HIPAA) of 1996 administrative simplification rules require a covered entity, such as a physician billing Medicare, to retain required documentation for six years from the date of its creation or the date when it last was in effect, whichever is later. HIPAA requirements preempt State laws if they require shorter periods. Your State may require a longer retention period.
The Centers for Medicare & Medicaid Services (CMS) requires records of providers submitting cost reports to be retained in their original or legally reproduced form for a period of at least 5 years after the closure of the cost report. This requirement applies to hospitals and not physician practices.
CMS requires Medicare managed care program providers to retain records for 10 years.
Privacy must be maintained even after record retention timelines have expired. While the HIPAA Privacy Rule does not include medical record retention requirements, it does require that covered entities apply appropriate administrative, technical, and physical safeguards to protect the privacy of medical records and other protected health information (PHI) for whatever period such information is maintained by a covered entity, including through disposal.
Additional information:
- Providers/suppliers should maintain a medical record for each Medicare beneficiary that is their patient.
- Medical records must be accurately written, promptly completed, accessible, properly filed and retained.
- Using a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries is a good practice.
- The Medicare program does not have requirements for the media formats for medical records. However, the medical record needs to be in its original form or in a legally reproduced form, which may be electronic, so that medical records may be reviewed and audited by authorized entities.
- Providers must have a medical record system that ensures that the record may be accessed and retrieved promptly.
Providers may want to obtain legal advice concerning record retention after CMS-required time periodshave been met.
Medicare Changes Rules on Credentialing and Retro-billing
Effective April 1, 2009, practices can only retro-bill for Medicare patients seen 30 days prior to the date the credentialing form was filed. The implications are:
- New physicians need to be credentialed prior to treating patients. This requirement should be part of the pre-employment checklist. The old days of credentialing a provider after they arrive onsite is over.
- Marketing activity to introduce new physicians to the community and medical staff should be scheduled after the credentialing is completed. Sometimes this can be tricky, however the referring providers can become disenfranchised when a new provider is not ready to schedule any of their patients.
- One option is to elect to see patients at no charge, both to provide needed care, and to begin establishing their practice.
- Another option is to have new physicians spend time in the community meeting potential surgeons and other referral sources. New physicians can also spend time giving talks and going with colleagues to satellite clinic locations or volunteer clinics.
- New physicians who are not credentialed can treat self-pay patients immediately. Some practices assign the new physician to the on-call physician to assist with emergencies, which are usually a high volume of uninsured patients.
The CMS system called PECOS (Provider Enrollment, Chain and Ownership System) or PECOS Web is available for enrolling or changing individual or group information. In addition to the retro-billing component for new and re-enrolling physicians, doctors are also required to alert Medicare contractors of a change in practice location within 30 days, via the 855i form. Failure to do so may result in expulsion from eligibility to see and be paid for Medicare patients for up to two (2) years. This is a new safeguard added by CMS to combat fraud.
Providers can us the links below to access the PECOS system:
- You must have an active National Provider Identifier (NPI) and have a web user account (User ID/Password) established in NPPES (https://nppes.cms.hhs.gov/NPPES/) .
- If you are a health care provider and do not have an NPI, create a web user account and apply for an NPI at NPPES (https://nppes.cms.hhs.gov/NPPES/) .
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