5010 – Ready or Not, Here It Comes (Part 2)

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It’s 2012 and HIPAA 5010 is officially here, yet many providers are still encountering difficulties as they transition their claims to be 5010 compliant. Recently, I wrote about the Top 5 potential roadblocks that could hold up reimbursements in 5010, which included changes to the fields used to report the billing provider address, ZIP code, drug information, anesthesia minutes and ambulance claims. To help providers continue with 5010 conversions, following is a list of six additional changes that may increase claims rejections if not addressed.

Billing Provider NPI. 5010 guidelines focus on creating uniform reporting of billing National Provider Identifiers (NPIs) to all payers. If the same NPI is not being consistently reported with all payers, the billing system needs to be analyzed to determine what NPI an office should be using for claims. Once a consistent NPI is developed, contact the payers’ provider relations offices to verify what steps to take in order to update the billing NPI with their organizations.

Primary Identification Code Qualifiers. Previously, an employer’s identification number or Social Security number could be reported as a primary identifier. In 5010, only a National Provider Identifier (NPI) can be reported as a primary identifier.

Insured (Subscriber) Group or Policy Number and Group Name. In 5010, the insured group field is now called the subscriber group and the policy number and the subscriber group name is now referred to as the policy number and the insured group name. You can report only one of these fields in each claim, with preference for reporting the group or policy number if it is available.

Health Care Diagnosis Code. In 4010, a maximum of eight diagnosis codes could be reported per claim. In 5010, you up to 12 diagnosis codes can be reported per claim, but only four codes can be linked to a specific service at the service line level. To accommodate claims that contain more than four diagnosis codes, additional service lines can be entered.

Line Item Control Number. Practices are now required to enter a unique line item control number for each line of service for each patient. In addition, payers are required to return the line item control number in the electronic remittance advice (ERA) transaction. This change is helpful because receiving the unique line item control number within the ERA gives allows providers to automatically post by service line.

Compound Drug Claims. In 5010, all individual ingredients that make up a compound prescription must be identified on the claim, and a unique Healthcare Common Procedure Coding System (HCPCS) must be assigned to each ingredient. The provider will be required to enter separate lines of service for each HCPCS.  As with single ingredient drugs, the provider must also include their service line charge for each ingredient, the service line associated units, the NDC number, the NDC drug quantity, and the composite unit of measure.  

As more and more payers convert to 5010 in the coming weeks, and as the deadline for full 5010 compliance approaches, providers should make getting their claims 5010-ready a top priority. If you haven’t already begun, I recommend that you reach out to your billing partners as soon as possible to make these and other 5010 changes so that your practice avoids increased rejections and continues to get reimbursed in a timely manner.

Jackie Griffin is client services director at Gateway EDI. For more tips on 5010, visit www.gatewayedi.com/5010.



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