5010 FAQs & Tips
5010 Tips
5010 Basics
Gateway EDI Technical Resources
Gateway EDI Testing
Gateway EDI Transition
Provider Actions
5010 Answers
5010 Tips
5010 Tip Of The Week – Billing Provider Address
Did you know, 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.
With the deadline approaching, Gateway EDI is here to help test your claims at every stage of your 5010 transition. If you haven’t started testing yet, please contact us at industryinfo@gatewayedi.com or 1-800-556-2231 to help you get started.
For more tips on 5010, visit www.gatewayedi.com/5010.
5010 Tip Of The Week – Nine Digit Zip Codes
Did you know, with 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, which can be accessed through the following link http://ZIP4.usps.com/ZIP4/welcome.jsp. Work with your software vendors to ensure they can capture the full nine digits for the billing provider and service facility addresses. To help our providers, we will default the last 4 bytes of the billing provider and service facility ZIP codes to ‘9998’ if received as blank to prevent claims from being rejected
With the deadline approaching, Gateway EDI is here to help test your claims at every stage of your 5010 transition. If you haven’t started testing yet, please contact us at industryinfo@gatewayedi.com or 1-800-556-2231 to help you get started.
For more tips on 5010, visit www.gatewayedi.com/5010.
5010 Tip Of The Week – Older Claim Formats
Did you know, after the 5010 transition on January 1, Gateway EDI will continue to support claims sent in older formats, such as ANSI 4010A1, NSF, CMS 1500 and CMS UB-04 print image formats, as well as the new 5010 format?
We know not all clients and practice management software vendors will be ready to use the new 5010 format. To support our clients and ensure their payments aren’t delayed, we will use our conversion process to translate any format you send us into a 5010-compliant format. In addition, some payers will not be ready to accept the 5010 format. We will identify and track these payers, so we can convert your 5010 files back into the format they need to process your claim.
5010 Tip Of The Week – Anesthesia Claims
Did you know, 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.
5010 Tip Of The Week – 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.
5010 Tip Of The Week – Drug Reporting
In 5010, professional claims for injectable medications must include additional drug information and qualifiers, such as National Drug Code (NDC), quantity and composite unit of measure.
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.
5010 Tip Of The Week – 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.
5010 Tip Of The Week – 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.
5010 Tip Of The Week – 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.
5010 Tip Of The Week – 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.
5010 Tip Of The Week – 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. If you send a NSF or print image format, please contact Gateway EDI for further instructions.
5010 Tip Of The Week – 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.
5010 Tip Of The Week – Institutional Claim Information Segment
The Institutional Claim Code segment, which includes the Admission Type Code and the Patient Status Code, will be required on all institutional claims in 5010. Previously, this was only required for inpatient visits.
In addition, the Admission Type Code has been changed to Priority (Type) of Admission or Visit, which you will use to indicate the source of a patient’s admission. Claims you submit in 5010 format will be rejected if a Priority (Type) of Admission or Visit value is not entered. If you do not submit a claim in 5010 format, Gateway EDI will default the value to 9 if no value is entered.
The Patient Status Code, which indicates the discharge status of the patient at the end of the statement coverage period, is now required on all claims. Claims you submit in 5010 format will be rejected if a Patient Status Code value is not entered. If you do not submit a claim in 5010 format, Gateway EDI will default the value to 30 for inpatient claims, and if a Discharge Date is present, we will default to 01.
Your billing systems will need to be able to capture and report this information on your electronic claims to avoid rejection.
5010 Tip Of The Week – Payer Transition
Transition is in full swing now that some commercial and Medicare payers have switched over to 5010 early to work out hiccups before the official transition date on January 1, 2012. As more payers transition to 5010 in the coming weeks, we recommend taking the following steps to help you continue to get paid in a timely manner.
- Monitor your rejection reports and remittance advice closely, especially claims in adjudication with payers.
- Check with your clearinghouse partner to see if they will send your claims in the format required by each of your payers throughout this transition.
5010 Tip Of The Week – Attending Provider for Institutional Claims
Previously, listing the Attending Provider (the individual who has overall responsibility for the patient’s medical care and treatment reported in the claim) was only required for inpatient claims (ANSI Loop 2310A). With 5010, you are required to include the Attending Provider on all institutional claims other than non-scheduled transportation claims.
Your billing systems will need to be able to capture and report this information on your electronic claims to avoid rejection.
5010 Tip Of The Week – National Drug Code
In 5010, professional claims for injectable medications must include additional drug information and qualifiers, such as the National Drug Code (NDC) number, which is used to identify a specific drug.
You can find the 11-digit NDC number printed on the drug package in a 5-4-2 format. The first five digits of the NDC identify the drug manufacturer, the next four identify the specific product and the last two identify the package size. If the segments do not have the appropriate number of digits, you will need to add zeros at the beginning of the segment. For example, if the package number is 1234-123-12, you will need to add zeros at the beginning of the segments to reach the required number of digits for the 5-4-2 format (01234-0123-12). When entering the NDC number in the service-line, you will enter all 11 digits without hyphens (01234012312).
Providers who submit service-line drug charges must work with their software vendor to ensure that the NDC number can be submitted in their claims.
5010 Tip Of The Week – 5010 Editing for Not Otherwise Classified (NOC) Codes
There’s a quick fix for new rejections related to non-specific or Not Otherwise Classified (NOC) procedure codes. With the switch to 5010, some providers are seeing a new rejection message like this one from WPS Medicare: “Acknowledgement/rejected for relational field in error. Detailed description of service.” If you are receiving these rejections, it means that you need to submit an additional description in one of these locations: the SV101-07 (2400 loop) for ANSI format, the Notes field on service lines for Print Image format, and theHA0 record for NSF formats. If you submit Print Image or NSF formats, please contact Gateway EDI for further assistance.
While the 4010 837 professional claim submission allows for use of the note (NTE) segment to include a description, 5010 specifically warns not to use the NTE segment. When you use NOC codes on the 5010 professional claim transaction (837P), the 5010 Technical Report Type 3(TR3) implementation guide instructs that you use SV101-7 for this purpose. The payer can provide the description needed for this submission.
The codes now requiring this information are listed in the article linked here.
http://www.wpsmedicare.com/part_b/publications/news/archived/2011-1108-5010-editnoc.shtml
5010 Basics
Who is required to make changes for 5010?
All covered entities are included in the 5010 industry-wide mandate. The definition for a covered entity is a health plan, a health care clearinghouse or a health care provider who transmits any health information in electronic form in connection with a HIPAA transaction.
Why is the electronic format for health care transactions changing again?
The current format, already eight years old, 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.
Does 5010 include changes for the CMS-1500 form for professional claims?
The 5010 standards control electronic transactions. The CMS-1500 form is maintained by the National Uniform Claim Committee (NUCC). NUCC has discussed minor changes to the existing CMS-1500, but no changes have been announced as of yet. The current form is Version 6.0, which was released July 1, 2010, with usage clarifications and appendices. No format or data requirements were implemented for 5010. For more details, you can visit the NUCC website at http://www.nucc.org/.
Will Gateway EDI continue to print my paper claims after the 5010 compliance date?
Yes, Gateway EDI will continue to offer claims printing services, regardless of the inbound format submitted by our customers.
Gateway EDI Technical Resources
When will Gateway EDI’s 5010 companion guides be available?
The updated 5010 Companion Guides are available for our clients and vendors on your secure Gateway EDI website. Navigate to Online Help in the top right corner, and when the new window opens, click on Transactions under Technical Resources.
Does Gateway EDI have help documents available for all 5010 changes?
Yes. On your secure Gateway EDI website, under Online Help and Transactions, Gateway EDI has support documents for high-level changes for claims, remittances and eligibility transactions. There are additional documents for institutional and professional claims as well.
Where are the Gateway EDI 5010 companion guides located?
The updated 5010 Companion Guides are available for our clients and vendors on your secure Gateway EDI website. Navigate to Online Help in the top right corner, and when the new window opens, click on Transactions under Technical Resources.
Gateway EDI Testing
Will every Gateway EDI customer have to submit test claims or can the practice management software vendor do the testing and Gateway EDI set all their customers to production on 5010?
If a Practice Management Software Vendor begins testing with Gateway EDI on behalf of their clients, after successful testing, the vendor can move clients over to 5010 as they are ready.
What are the requirements for a 5010 test file?
A 5010 test file, regardless of format, must include a minimum of 25 claims. Gateway EDI recommends including all provider specialties in your office and a variety of payers. This will ensure the most accurate test results.
Where can I see Gateway EDI’s testing schedule with payers and trading partners?
You can find the Gateway EDI testing schedule with payers and trading partners on your secure Gateway EDI website by clicking the Payer List under the Resources tab. Beginning in April 2011, there will be additional fields added for the projected testing dates, the testing status and the production date for each payer.
If I pass testing, when do I start sending 5010 files?
Once you have been notified by a Gateway EDI associate that you have passed testing, we will work with vendors and clients on a mutually agreed date to go live with 5010.
Where can I see Gateway EDI’s production information for specific payers and trading partners?
Clients can find the Gateway EDI testing schedule with payers and trading partners on their secure Gateway EDI website by clicking the Payer List under the Resources tab. The Payer List includes the production date for each payer.
What do I do now if I upgraded to 5010?
If you have upgraded your format to the 5010 format, you can send claims in production. It is important that you monitor your rejections closely and make any necessary changes.
Gateway EDI Transition
Will Gateway EDI process both 4010A1 and 5010 transactions during the transition period? Is there a cutoff date for 4010A1?
Gateway EDI will accept versions 4010A1 and 5010 during the 2011 transition year and beyond. There are no plans for Gateway EDI to discontinue accepting version 4010A1. We will continue to accept version 4010A1 after the compliance date of January 1, 2012, and will run those files through our conversion process to create 5010 compliant claims. This means Gateway EDI can accommodate the varying degrees of readiness among payers, providers, trading partners and other information partners.
Which claim formats will Gateway EDI support when 5010 is implemented?
Gateway EDI will continue to support institutional and professional claims sent in ANSI 4010A1 837, NSF, and both CMS 1500 and UB04 print image formats.
If you are unsure what format you use or would like more information about your claims format, please contact Gateway EDI at industryinfo@gatewayedi.com. We will work with you and your vendor to ensure that your claims will be compliant HIPAA 5010 claims in time for the deadline, January 1, 2012. We will post information on our public website and your secure Gateway EDI client website regarding the 5010 changes and details about our testing procedures and requirements.
In regards to ICD-10, has Gateway EDI started on this project yet?
Yes. We have a plan in place to provide accurate and timely assistance to effectively implement ICD-10 on time. 5010 is a major step in supporting the new ICD-10 codes that will be required for use on October 1, 2013.
Will Gateway EDI be creating readable reports for the new 5010 Acknowledgement reports (999, 277CA, 997 and 824)?
Although it has been said that some clearinghouses will not be offering these reports, Gateway EDI will be translating all payer reporting into readable reports on our website just as they are today.
Provider Actions
What will happen to a claim that does not contain the required ZIP code information?
Each payer may handle 5010 claims differently. Some may accept a 5-digit ZIP code or a 5-digit ZIP code plus a 4-digit numeric placeholder such as 9998. Gateway EDI has been advised by many payers that claims will be denied, returned as un-processable and even deleted from the payer’s systems if a valid 9-digit ZIP code is not present on the claim.
Will I have to submit a 9-digit ZIP code on all addresses that appear on a claim?
No. Providers must submit a full 9-digit ZIP code only when reporting Billing Provider and Service Facility locations.
How can I determine my 9-digit ZIP Code?
The best way to determine the 4-digit extension to your standard ZIP code is by contacting the United States Postal Service. They offer online access to their ZIP Code Lookup Tool, which can be accessed through the following link http://ZIP4.usps.com/ZIP4/welcome.jsp.
What if I am not ready to submit or receive 5010 transactions on January 1, 2012? Can I still use Gateway EDI as a clearinghouse?
Yes. Gateway EDI will offer dual processing, which means we will convert inbound formats such as 4010A1 ANSI, NSF and CMS 1500 print image into a compliant 5010 outbound transaction. In addition, we will convert the 5010 transactions from payers and forward those back to you in the same easy-to-read form you receive today.
Can I still have payments sent to a lock box or post office box?
Yes. If you use a PO Box or lock box address as your location for payments and correspondence from payers, you can continue to use this approach, however; you must report this location as a Pay-to Address. (2010AB loop for ANSI claims). The Pay-To Provider address is only needed if it is different than that of the Billing Provider and providers should work with their software vendors to ensure that the correct addresses are captured and sent in the correct locations for the 5010 implementation deadline.
Will I have to submit a physical address on a claim (street number and name) in the billing provider address?
Yes. The Billing Provider Address reported must be a physical address. PO Box and lock box addresses cannot be reported as a Billing Provider Address once 5010 is implemented. This rule applies to both professional and institutional claim formats. Providers should work with their software vendors to ensure that the correct addresses are captured and sent in the correct locations for the 5010 implementation deadline.
What do I need to do to ensure that my practice is ready for the changes?
- Check back here regularly for easy-to-understand updates and provider requirements
- Use our resources tab for helpful 5010 links
- Visit the CMS 5010 checklist here: www.cms.gov/Versions5010andD0/Downloads/w5010PvdrActionChklst.pdf
- For any questions, please email our Industry Initiatives Department at industryinfo@gatewayedi.com
I’m in a rural area and have a PO Box because there is no mail delivery. Should my Billing Provider Address be my mailing address?
No. The Billing Provider Address is the address where the services were rendered. This location address may or may not be the same as the mailing address. If your mailing address is a PO Box, it will be reported as a Pay-to Address only.
The address I used in the NPI database and enrolling with my payers is not my street address. Will this cause a problem?
This could pose a problem. Most payers use the address you reported on your enrollment application in their provider files. You may need to update your records with them. If your payer(s) use the address you reported in the NPI Registry along with your NPI to identify you in their system, you will need to update your address information in the NPI Registry. You should visit the National Plan & Provider Enumeration System’s (NPPES) website at https://nppes.cms.hhs.gov/NPPES/Welcome.do and also contact your payers to update your address information.
Why is it important to use a consistent billing NPI when filing 5010 claims?
By using the same NPI for all payers, providers will no longer have to modify their billing NPI based on the payer being sent a specific claim. This new requirement will also help payers that receive crossover or secondary claims, by eliminating the need to identify providers differently than they do when receiving primary claims.
Will the 5010 NPI requirements affect the reporting of our billing NPI?
The new guidelines focus on creating uniform reporting of billing NPIs to all payers. Providers who are not consistently reporting the same NPI with all payers may be required to re-examine their current billing practices and adjust accordingly.
Will I still be able to use an individual NPI when billing?
A billing NPI is most commonly an organizational NPI. Once 5010 is in place, individual NPIs will only be allowed to be sent as the billing NPI when services were performed by, and will be paid to, an independent, non-incorporated individual.
Will all payers enforce NPI consistency as of January 1, 2012?
Some payers may continue to accept different NPIs, making advance communication with payers an important step in your planning. While NPI consistency is a key component of 5010, it is at the payers’ discretion to enforce it. There is not a regulating body over the use of NPIs.
Will I have to re-enroll if we decide to change our billing NPI with a particular payer?
Re-enrollment is necessary if your practice decides to change the NPI you are submitting to a particular payer.
What can I do now to ensure my billing NPI is consistent?
Review your billing system to identify what NPI your office sends to each payer. Communicate the differences in NPI reporting to those in your office responsible for billing and determine what NPI your office should be using for claims. Then you can contact the payers’ provider relations offices to verify what steps to take in order to update your billing NPI with their organizations.
What should I do if I determine that I do need to make changes to my billing NPI?
If changes need to be made, communicate this information as soon as possible to your trading partners, including clearinghouses, payers, software vendors and other business partners. They may need to make changes to their systems so they can recognize a different billing NPI and associate it with your practice. This is an important step to complete well in advance of January 1, 2012, to provide adequate time for new enrollment forms to be processed, if needed.