CMS-10381 CMS-10381.Appendix D Version 5010 ICD-10 Industry Readin

OMB Approval No.: 0938-xxxx
Approval Expires: xx/xx/20xx

Version 5010/ICD-10 Industry Readiness Assessment
Revised February 23, 2011
Background
The questions that follow are designed to gauge the health care industry’s awareness of and preparation
for the transition to Version 5010 and ICD-10. The survey is being conducted for the Centers for
Medicare & Medicaid Services (CMS) and should not take longer than 15 minutes. Your participation is
voluntary and your responses are confidential; only de-identified, aggregated data will be provided to
CMS. This information will be used to inform outreach and education efforts to help health care
providers, payers, software vendors and clearinghouses prepare for the coming transitions.
1. Please select the term below that best describes your organization [Please select one response]:
1. Provider practice, small (10 or fewer physicians )
2. Provider practice, large (11 or more physicians)
3. Hospital, small (99 or fewer beds)
4. Hospital, large (100 or more beds)
5. Payer (private)
6. Payer (public, e.g., Medicaid, TRICARE)
7. Other insurer (e.g., property and casualty)
8. Software vendor
9. Clearinghouse
10. Third-party biller
11. Third -party administrator
12. Other (specify)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection will be entered after
clearance. The time required to complete this information collection is estimated to average 15 minutes per response, including
the time to review instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to: CMS, Office of E-Health Standards and Services (OESS), Administrative Simplification Group, Attention:
OMB Approval Number, Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850

2. [IF Q1=1-7, 9-11] Which of the following statements best describes your responsibility in your
organization’s Version 5010 and ICD-10 transitions? [Please select one response.]
 I am the most senior person responsible for preparing the company for the transition
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 I am not the most senior person, but am involved in the transition and I have significant
input or influence into the decisions regarding the systems and/or procedures that will be
implemented
 I make recommendations regarding the systems and procedures that will be implemented,
but am not a decision-maker [TERMINATE]
 I provide support (and work with the systems used) for reporting patient information for
billing and reimbursement, but have no influence over what procedures or systems are
implemented [TERMINATE]
 None of the above [TERMINATE]

3. [IF Q1=8] Which of the following statements best describes your role when it comes to marketing
the systems/solutions/services you offer or will offer your healthcare clients to assist them in the
transitions to Version 5010 and ICD-10? [Please select one response.]
 I am the most senior person in the company responsible for marketing these
systems/solutions/services
 I am not the most senior person, but I have significant input or influence into the decisions
regarding marketing these systems/solutions/services
 I make recommendations regarding marketing these systems/solutions/services, but the
final marketing decisions are made by someone else [TERMINATE]
 I will implement the marketing or sell these systems/solutions/services, but have no
influence over marketing decisions [TERMINATE]
 None of the above [TERMINATE]

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About the Version 5010 Transition on January 1, 2012
On January 1, 2012, standards for electronic health care transactions change from Version 4010/4010A1
to Version 5010. These electronic health care transactions include functions like claims, eligibility
inquiries, and remittance advices. Unlike the current Version 4010/4010A1, Version 5010
accommodates the ICD-10 codes, and must be in place first before the changeover to ICD-10. The
Version 5010 change occurs well before the ICD-10 implementation date to allow adequate Version
5010 testing and implementation time.
If providers do not conduct electronic health transactions using Version 5010 as of January 1, 2012,
delays in claim reimbursement may result. If health plans cannot accept Version 5010 transactions from
providers, they may experience a large increase in provider customer service inquiries affecting their
operations.
Preparing for ICD-10 and Version 5010 – including potential updated software installation, staff training,
changes to business operations and workflows, internal and external testing, reprinting of manuals and
other materials, and more – will take time.
Directions:
Please read About the Version 5010 Transition above before answering the following questions.
1. Did you know about the Version 5010 transition before reading the information above?
 Yes
 No
 Not sure
2. Did you know about the January 1, 2012, deadline for the Version 5010 transition?
 Yes
 No
 Not sure
3. Is your organization taking action to prepare for Version 5010?
 Yes
 No
 Not sure
4. Do you think your organization will be Version 5010 compliant by the January 1, 2012, deadline?
 Yes [Skip to Question 6]
 No
 Not sure
5. What are the obstacles and challenges to reaching compliance by January 1, 2012? [Please
select all that apply]
 Impact analysis not conducted
 Inadequate budget/funding
 Lack of incentive
 Lack of time and/or staff
 Internal testing not complete
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




External testing not complete
Lack of coordination with vendor(s)
Other health care transition(s) taking priority (i.e., Meaningful Use)
Other [please specify]

[Please indicate your planned timing for the following activities for the Version 5010 transition.]

Don’t know

Not planning for this activity

Oct-Dec 2013

Jul-Sept 2013

Apr-Jun 2013

Jan-Mar 2013

Oct-Dec 2012

Jul-Sept 2012

Apr-Jun 2012

Jan-Mar 2012

Oct-Dec 2011

Jul-Sept 2011

Apr-Jun 2011

Jan-Mar 2011

Nov-Dec 2010

Already Complete

Activity
6. Conduct impact
analysis
7. Talk with your
software
vendor/developer about
transition plans
8. Secure budget (time
and costs related to
implementation)
9. Begin internal testing
(e.g., test changes in
software, practice within
your organization to
successfully create/
receive 5010-compliant
transactions)
10. Complete internal
testing
11.Begin external testing
(e.g., between providers,
payers/clearinghouses)
12.Complete external
testing
13. What is your
projected date to be
5010 compliant?
14. Conduct staff training
SOFTWARE/HEALTH IT
DEVELOPERS/VENDORS

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15. System development
16. Product rollout
17. Conduct customer
education
18. Live production
operations using version
5010 standards

About the ICD-10 Transition on October 1, 2013
ICD-10 codes must be used on all HIPAA transactions, including outpatient claims with dates of service,
and inpatient claims with dates of discharge on and after October 1, 2013.
Otherwise, provider claims and other transactions may be rejected, and providers will need to resubmit
them with the ICD-10 codes. This could result in delays and may impact reimbursements, so it is
important to prepare now for the changeover to ICD-10 codes.
This change does not affect CPT coding for outpatient procedures.
Directions:
Please read About the ICD-10 Transition above before answering the following questions.
1. Did you know about the ICD-10 transition before reading the information above?
 Yes
 No
 Not sure
2. Did you know about the October 1, 2013, deadline for the ICD-10 transition?
 Yes
 No
 Not sure
3. Is your organization taking action to prepare for ICD-10?
 Yes
 No
 Not sure
4. Do you think your organization will be ICD-10 compliant by the October 1, 2013, deadline?
 Yes [Skip to Question 6]
 No
 Not sure
5. What are the obstacles and challenges to reaching compliance by October 1, 2013? [Please
select all that apply]
 Impact analysis not conducted
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








Inadequate budget/funding
Lack of incentive
Lack of time and/or staff
Internal testing not complete
External testing not complete
Lack of coordination with vendor(s)
Other health care transition(s) taking priority (i.e., Meaningful Use)
Other [please specify]

[Please indicate your planned timing for the following activities for the ICD-10 transition.]

Don’t know

Not planning for this activity

Oct-Dec 2013

Jul-Sept 2013

Apr-Jun 2013

Jan-Mar 2013

Oct-Dec 2012

Jul-Sept 2012

Apr-Jun 2012

Jan-Mar 2012

Oct-Dec 2011

Jul-Sept 2011

Apr-Jun 2011

Jan-Mar 2011

Nov-Dec 2010

Already Complete

Activity
6. Conduct impact analysis
(e.g., identify potential changes
to work flow)
7. Develop ICD-10
implementation plan
8. Talk with your business
trading partners (providers,
payers, vendors) about
transition plans
9. Secure budget (time and
costs related to
implementation)
10. Begin internal testing (e.g.,
test changes in software,
practice within your
organization)
11. Complete internal testing
12. Begin external testing
(e.g., between providers,
payers/clearinghouses)
13. Complete external testing
14. What is your projected
date to be ICD-10 compliant?
15. Conduct staff training
SOFTWARE/HEALTH IT

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DEVELOPERS/VENDORS
16. System development
17. Product rollout
18. Conduct customer
education
19. Live production operations
using ICD-10
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