Why 5010 ?
The current format, is unable to meet some important new developments in health care such as supporting the ICD-10 code set and pay for performance. Other changes in the 5010 version will streamline reimbursements. Most of the changes are technical and geared toward improved standardization and uniformity. Many of these can be handled by your vendor and clearinghouse. However, it is important that you understand your own responsibilities in order to become 5010 compliant.
Billing Provider Address
With 5010, the Billing Provider Address you use on claims must be a physical address? Once 5010 is implemented, you can no longer use PO Box and lock box addresses as a billing provider address. This rule applies to both professional and institutional claim formats. However, you can still use a PO Box or lock box address as your location for payments and correspondence from payers as long as you report this location as a pay-to address. The pay-to- provider address is only needed if it is different than that of the billing provider. Work with your software vendor to ensure the correct addresses are captured and inserted in the necessary locations on your claim submission.
Nine Digit Zip Codes
In 5010, providers must submit a full 9-digit ZIP code when reporting billing provider and service facility locations? An easy way to determine the 4-digit extension to your standard ZIP code is to look it up on the U.S. Postal Service’s ZIP Code Lookup Tool. Work with your software vendors to ensure they can capture the full nine digits for the billing provider and service facility addresses.
Anesthesia Claims
In 5010, you must report anesthesia services in minutes rather than units if the procedure code does not define a specific time period? However, if the procedure code has minutes in its description, then you can continue to report those charges in units.
When you need to manually calculate the time period, you can only use minutes for the time measurement. For example, if the total time of anesthesia services is one hour and thirty minutes, services should be submitted as 90 minutes.
Anesthesia providers should verify that their systems can manage this change.
Subscriber vs. Patient Clarification
With 5010, the insurance plan subscriber/patient hierarchy has been clarified. Two possible situations can occur:
- If the patient has a unique member identifier assigned by the payer, then the patient is considered to be the plan subscriber and is sent as the subscriber. There is no need to also enter their information in the patient section on the claim.
- If the patient is a dependant of the plan subscriber and does not have their own unique member identifier, then both the subscriber and patient information will be required on the claim.
Providers must check the patient’s insurance card and/or check patient eligibility to ensure the information is appropriately documented for accurate submission in 5010.
Drug Reporting
In 5010, professional claims for injectable medications must include additional drug information and qualifiers, such as National Drug Code (NDC), quantity, composite unit of measure and prescription number.
Currently providers must submit a HCPCS code as the service-line procedure along with the total charge and units of service. In 5010, you will now be required to also submit the NDC Drug Quantity and Composite unit of measure. Providers who submit service-line drug charges must work with their software vendor to ensure that the drug quantity and unit of measure can be submitted. Claims that do not include this information may be rejected.
Providers should work with their software vendors to determine if the product supports these and other drug entry changes.
Compound Drug Claims
The 4010 standards made it difficult to select a single HCPCS code for a compound injectable medication because each ingredient pointed to a different HCPCS code. In 5010, all ingredients that make up a compound prescription must be identified on the claim, and a unique 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.
Providers should work with their software vendors to determine if the product supports these and other drug entry changes.
Durable Medical Equipment
The Durable Medical Equipment (DME) Service segment (2400 SV5) is used when it is required to report both the rental and purchase price information for durable medical equipment at the service line level. In 4010, only the procedure code, unit of measurement and quantity were required for this entry. In 5010, the DME Rental Price, DME Purchase Price and Rental Unit Price Indicator will also be required. If all three of these fields do not contain a valid value, the claim will be rejected.
Some claims may also require the DME Condition Indicator segment (2400 CRC) for a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN), a DMERC Information Form (DIF), or an Oxygen Therapy Certification. In 4010, you could repeat the segment more than once, but 5010 limits you to one DMERC condition indicator segment per service line. The number of condition indicator codes for this segment has also been reduced from five possible codes in 4010 to only two codes in 5010. If invalid indicator codes are used, the claim will be rejected.
Ambulance Claims
In 5010, ambulance suppliers who submit medical transportation claims will be required to report the pick-up and drop-off locations for ambulance transport. Previously, there were no dedicated fields for this information, but now it can be reported at the claim level (5010 loops: 2310E and 2310F) and service line level (5010 loops: 2420G and 2420H). 5010 also added another new segment (2400 QTY) that will be required to report the number of patients transported in the same vehicle for ambulance or non-emergency transportation services.
Additionally, CMS currently does not require ambulance suppliers to submit a diagnosis code on claims for payment. However, in 5010, a diagnosis code must be present on all professional electronic claims, including ambulance claims.
Your billing systems will need to be able to capture and report this information on your electronic claims to avoid rejection.
Line Item Control Number
While some practices have been entering a unique line item control number for each line of service for each patient, it will now be required to be unique in 5010. The line item control number segment is not required but if it is sent it will need to be unique to each line of service. In addition, payers are required to return the line item control number in the electronic remittance advice (ERA) transaction when the provider includes it in the original electronic claim or when they have split the claim or line item. This change is helpful because receiving the unique line item control number within the ERA gives you the capability to automatically post by service line.
If providers send a line item control number they should work with their software vendors to verify that their systems can create a unique line item control for each line of service.
Health Care Diagnosis Codes for Professional Claims
One of the main purposes of 5010 is to support the upcoming change to ICD-10 diagnosis and procedure codes – a change providers must make by October 1, 2013. To help prepare for ICD-10, 5010 now requires a Diagnosis Code on all claims, and the maximum number of Diagnosis Codes was increased from eight in 4010 to 12 in 5010. Although you can report 12 diagnosis codes at the claim level, you can only point or link four codes to a specific service at the service line level.
You need to work with your software vendor to ensure you have the ability to report the number of required diagnosis codes.
Primary Identification Code Qualifiers
Previously, you were allowed to report an Employer’s Identification Number (Tax ID) or Social Security Number (SSN) as a primary identifier for the billing provider. In 5010, you are only allowed to report a National Provider Identifier (NPI) as a primary identifier (ANSI loop 2010AA NM108/NM109). If the billing provider does not qualify for an NPI number, such as an Atypical provider, then only the Tax ID or SSN would be allowed in the REF segment of the billing provider loop.
In addition, 5010 standards have eliminated the use of payer-specific provider numbers in favor of NPI and Tax ID numbers.
