There is absolutely no denying it now – 5010 is here, and we’re all feeling the weight of it. Over the past few weeks, I’ve been presenting on 5010 with associations and talking with representatives from all different areas of the industry to get a feel for the main points of pains that are out there.

What I’ve found is that, whether or not your practice has transitioned to 5010, most likely you’ve been facing an increased number of rejections. We knew that everyone that touches medical claims would deal with issues during a transition of this size, but many people were not ready for an impact of this magnitude. Providers, PMS vendors, clearinghouses and payers are all experiencing challenges processing claims in 5010, and as a result of that, your claims are being delayed.

Here are three common issues I’ve been seeing:

1. File Acknowledgement Reports: 5010 changes the way claims are formatted, which also changes the format of the reports payers send back, such as the file acknowledgement report (999) that notifies us when the payer has accepted or rejected your claim. We’re finding that payers are implementing the use of acknowledgement reports  in different ways, resulting in more rejections at the 999 level. We are seeing claim files rejecting at the 999 level for reasons such as – an unrecognized provider identifier or invalid member ID, for example – and these types of issues result in immediate delays in claim processing. Identifying and correcting these issues for each payer has been time-consuming for clearinghouses. We are working closely with all payers to resolve issues as timely as possible.
2.  Payer Transitions to 5010: Migrating all insurance companies over to the new 5010 format was challenging. Some began moving to 5010 without informing their trading partners or failed to make the switch to 5010 on the date they originally planned, leading to claims getting stuck unexpectedly. While your billing partners can resolve these issues, it can take several days to uncover and address these hold-ups.
3.  Interpretation of Standards: While 5010 establishes standards for coding, the way people are interpreting these standards is not always consistent. When payers interpret standards for claims differently than the provider or biller who submits them, the claims will be rejected. If your clearinghouse knows how the payer is applying the standards, it can identify any discrepancies in your claims and provide direction on which areas to address before submitting the claim to the payer. Since the industry is still in the beginning stages of the transition we are all still learning and understanding how each entity has interpreted and implemented the new standards. During this time you will see an increase in rejections which will impact your cash flow. 

What Can You Do?

If you haven’t already felt the impact of these challenges, you will. In the next month or two, almost all providers can expect to see claims held up due to rejections. Here are some tips to help you get over the most recent industry hurdles:

• Know what new claims data is needed for the 5010 format. While your PMS vendor or clearinghouse can help convert your claims to meet 5010 compliance, we can only work with the data your practice provides. If new requirements, like the nine-digit Zip code and billing provider address, are not submitted at all, your claim cannot be converted and sent. For examples of whatnew data is required, you can visit: https://www.cms.gov/Versions5010andD0/01_overview.asp#TopOfPage 
• Monitor your rejections both at the EDI level and in your remittance advice (EOB), where claims are adjudicated at the payer. This will help you track the progress of your claims and identify and address issues early to avoid delays in your reimbursement.
• Network with other practices in your specialty to learn what challenges they have encountered, and how they are resolving them.
• Check out what industry associations are saying about the transition. They can give you noticeof industry-wide challenges, as well as recommend ways to operate more efficiently in 5010.

While times seem dark, remember that we have experienced this level of industry change before with the transition to 4010 and to NPI, and as with those transitions, the industry got back on its feet after a few months of working through the kinks.

How is your practice weathering the 5010 transition?

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

Gateway EDI, a medical claims clearinghouse, recently announced that 20 providers working with PCIP were named to the Gateway EDI 99% Club in November. The 99% Club recognizes practices that have less than 1% of claims rejected, resulting in outstanding efficiencies and financial performance.  Read the full article here.

Recently, the Centers for Medicare & Medicaid Services announced they will not take enforcement actions against HIPAA covered organizations that are not 5010 compliant until March 31, 2012. This may sound like you have an extended deadline to become 5010 compliant. But, it is simply advising that there will be a 90-day grace period before enforcement actions will be taken.

The reality is that 5010 is already here. To avoid a traffic jam and potential melt down, the industry began the conversion ahead of schedule to work out the kinks before the official transition date. This means providers may already be experiencing an increase in claim rejections. Monitor your rejection reports for these top five potential road blocks that could hold up your reimbursements.

1. Billing Provider Address
   5010 guidelines require providers to enter the billing provider as a physical address. If a PO Box or lock box address is necessary for payments and correspondence from payers, it must be reported as a pay-to address. This rule applies to both professional and institutional claim formats.
2. 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. You will also be required to report the number of patients transported in the same vehicle for ambulance or non-emergency transportation services. There were previously no designated fields for this information, so you will want to ensure that these fields are added to your claims.
3. Drug Reporting
   5010 professional claims for injectable medications must include additional drug information and qualifiers, such as NDC code, quantity, composite unit of measure and prescription number, in addition to the HCPCS code.
4. Zip Code
   In 5010, providers must submit a nine-digit zip code when reporting billing provider and service facility locations (click here to determine the 4-digit extension to your standard ZIP code). Providers should work with their software vendors to ensure they can capture the full nine digits for the billing provider and service facility addresses.
5. Anesthesia Minutes
   In 5010, anesthesia services must be reported as minutes. Units may only be reported for anesthesia services when the code description includes a time period or indicates that the time is assigned to a primary code.

The resolutions to these data entry changes are rather technical. I encourage your office to work closely with your practice management software vendors and other billing partners, so you continue to get reimbursed in a timely manner.

5010 is here now, and we’ve heard from many providers who thought they had more time. What do you think about the industry’s preparation for 5010? And, what has been your practices’ biggest point of pain with the transition?

Jackie Griffin is client services director at Gateway EDI. For more details on other common 5010 rejections, visit http://www.gatewayedi.com/5010/faq/.

Visit the following link to access the files. http://www.cms.gov/ICD10/11b14_2012_ICD10CM_and_GEMs.asp 

You can also find the 2012 ICD-10-PCS (procedure) files at http://www.cms.gov/ICD10/11b15_2012_ICD10PCS.asp

Continuing education credits may be awarded by the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA) for participation in CMS National Provider Conference Calls.

The podcasts, video slideshows, and written transcript are now available on the CMS website at http://www.cms.gov/ICD10/Tel10/itemdetail.asp?itemID=CMS1249632.

The appendix of each handbook references relevant templates which are available for download in both Excel and PDF files below. The templates are customizable and have been created to help entities clarify staff roles, set internal deadlines/responsibilities and assess vendor readiness.

Click here to view the tailored step-by-step plans and relevant templates for each of the following audiences:

• Large Provider Practices
• Payers
• Small/Medium Provider Practices
• Small Hospitals

For more information on how Gateway EDI is helping our customers prepare for ICD-10, visit www.gatewayedi.com/icd10.

How Does this Impact Your Organization?

This may sound like you have an extended deadline to become 5010 compliant. But it is simply advising that there will be a 90-day grace period before enforcement actions will be taken.

The CMS announcement does not change Gateway EDI’s transition plan to meet the January 1, 2012 compliance date. We will continue assisting clients to reach 5010 standards by the deadline.

On January 1, 2012, providers must change to a new standard format for submitting electronic claims information or face potential delays in reimbursement. However, nearly half of all practices haven’t even begun implementation, according to a recent MGMA member survey.

The switch from the current 4010A1 format to the new 5010 format requires substantial changes to the claims information you submit. It is extremely important that you are aware of these HIPAA changes and take the necessary steps to be in compliance by the January 1 deadline. If these changes are not made, payers may not be able to process your claims.

The Centers for Medicare and Medicaid Services (CMS) mandate includes upgrading the current electronic transaction standard for health care claims, remittance advices, eligibility and claims status to X12 version 5010. Since the changes cover the data you submit with your claims as well as the data you receive in response to your electronic inquiries, implementation may require changes to the software, systems and procedures you use for billing your transactions.

Gateway EDI is here to help you through the 5010 conversion process. From helping test your claims to providing strategies to minimize the impacts to your practice, we are ready to ensure that your practice’s transition proceeds seamlessly and on time.

To assist you with planning a smooth transition, some of the following CMS guidelines outline questions to consider with your team. These steps will help identify actions for your office to take prior to the transition, plans for coordinating with your software vendors, clearinghouses, billing services, and payers, and impacts on your practice’s data reporting requirement changes, workflow modifications and testing.

Talk to your software vendor early: Your software vendor is the company that supports your practice management system. You will need to contact them to determine what version you are currently using and what you will need to be 5010 compliant. Questions to consider asking:

• Will you be upgrading your current system to accommodate Version 5010 transactions?
• What is the time frame for when you will be able to support Version 5010 transactions?
• Will you be able to support both Version 4010A1 and Version 5010 transactions at the same time?
• When will upgrades be available?
• Will there be a charge for upgrades or will my current charges increase?
• When will software installations be completed for Version 5010?
• If there will be an update to our system, what fields are being added or changed?
• What business processes will be affected by 5010?

Identify changes to data reporting requirements: Data reporting requirements and questions for your own team to consider include:

• What data reporting changes will affect the transactions we use?
• What resources can we use to help us identify the data reporting changes? Will there be a cost?
• Can the new data be stored in our office’s current system or will it require a system upgrade?
• If our software vendor stated that there will be an update to our system, what fields are being added or changed?
• How do these changes fit into our existing operations?
• Will we need to purchase additional hardware for the new reporting requirements?
• Based on data changes needed for our practice, does anyone in our office need to be trained on workflow changes?
• Which requirements for testing 5010 transactions are relevant to our work?
• What kinds of transactions do we need to have tested?
• Do our vendors’ testing plans cover all of our needs?

Talk to your trading partners: Trading partners include all organizations involved in the end-to-end exchange of electronic health care data and transactions, such as payers, providers, clearinghouses, billing services, network service vendors and data transmission services. If you utilize a billing service, you need to contact them to determine their plan for 5010. If you send claims directly to any payers, you will need to contact them. To learn more about Gateway EDI’s transition plan, visit www.gatewayedi.com/5010.

To help you plan these conversations, questions to consider asking your trading partners include:

• Will you be upgrading your systems to accommodate 5010 transactions?
• When will each of the upgrades be completed?
• Will there be additional fees for these upgrades?
• Do the upgrades require changes to the way we work with you today?
• When can we test for 5010 to ensure the system works properly?
• Do you have connections to multiple trading partners and will you be testing with all of them?
• Do we need to use test data or live data during testing?
• What are your requirements for testing 5010 transactions?

Plan your next steps: Testing is a very important part of the transition to 5010. Gateway EDI is here to help with testing your claims and every stage of your 5010 transition. For answers to common questions about the transition and testing for 5010, please visit http://www.gatewayedi.com/5010/faq/.

It’s also a good idea to talk with your peers about the changes they have to make and what they are doing to prepare. Check with the industry associations you belong to for upcoming discussions and events.

The following resources also offer assistance regarding the 5010 transition:

• CMS Side-by-Side Comparison Documents for the 5010
  www.cms.gov/electronicbillingeditrans/18_5010d0.asp
• Washington Publishing Company – purchase the 5010 Implementation Guides
  www.wpc-edi.com
• The American Medical Association (AMA) – 7 Steps Practices Can Take Now to Prepare for 5010
  http://www.ama-assn.org/ama1/pub/upload/mm/399/5010-seven-steps.pdf