Today’s post comes from one of the contributors to the ICD-10 PlayBook, Version 2, Gateway EDI. This is the second of a two-part series on tips for 5010 compliance (see link below). Contact me at firstname.lastname@example.org with questions or comments. And I look forward to hearing from you. Juliet A. Santos, HIMSS Senior Director, Business-Centered Systems
by Jackie Griffin
It’s 2012 and 5010 is officially here, yet many providers are still encountering difficulties as they transition their claims to 5010 compliance.
Recently, I posted about the top five potential roadblocks that could hold up your 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 you continue with your 5010 conversion, I’ve provided a list of seven more changes that may increase your claims rejections.
1. Billing Provider NPI
5010 guidelines focus on creating uniform reporting of billing National Provider Identifiers (NPIs) to all payers. If you are not consistently reporting the same NPI with all payers, you may need to review your billing system to determine what NPI your office should be using for claims. Once you develop a consistent NPI, contact the payers’ provider relations offices to verify what steps to take to update your billing NPI with their organizations.
2. Billing Provider Address Location
5010 guidelines require the billing provider’s physical address. If the billing provider has one NPI and one location, enter the physical address of the office. If you have one NPI covering multiple office locations, report the physical address of the primary office, as identified in the National Plan and Provider Enumeration System (NPPES) and/or enrolled with the payer. Finally, those that have a separate NPI for each office location should report the physical address associated with the NPI being billed and as registered in NPPES. Be sure to check with your payers before making changes to addresses, and look for more on this topic in an upcoming white paper from the Workgroup for Electronic Data Interchange (WEDI).
3. 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.
4. Insured (Subscriber) Group or Policy Number and Group Name
In 5010, the insured group field is now called the subscriber group; the policy number and the subscriber group name is now called 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.
5. Health Care Diagnosis Code
In 4010, a maximum of eight diagnosis codes could be reported per claim. In 5010, you can report up to 12 diagnosis codes per claim, but you can only link four codes to a specific service at the service line level. To accommodate claims that contain more than four diagnosis codes, you can enter additional service lines.
6. 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 must 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 you the ability to automatically post by service line.
7. 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 its 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, your practice should make getting your 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.
How has the 5010 transition process been going for your organization?
Jackie Griffin is client services director at Gateway EDI. For more tips on 5010, visit www.gatewayedi.com/5010.