For 5010 Compliance, Non-specific Codes Require More

Reporting a non-specific procedure code for a medical service or supply may seem like the simplest solution, but version 5010 makes it a bit more complicated. The new electronic transaction standard, implemented Jan. 1, requires providers and suppliers acting under the Health Insurance Portability and Accountability Act (HIPAA) to also include a corresponding description of the service or supply.

Although HIPAA enforcement of 5010 compliance is deferred until March 31, providers would do well to ensure this implementation guide requirement is followed when submitting a HIPAA-compliant claim for all non-specific procedure codes.

Non-specific procedure codes are those that include in their descriptors:

  • Not Otherwise Classified (NOS)
  • Unlisted
  • Unspecified
  • Unclassified
  • Other
  • Miscellaneous
  • Prescription Drug Generic
  • Prescription Drug, Brand Name

When billing a procedure code containing any of these terms, you must include a corresponding description of that procedure to be HIPAA-compliant. There is no crosswalk of non-specified procedure codes with corresponding descriptions; however, the claim will not be rejected if “Not Otherwise Classified” is submitted as the description.

Detailed information regarding this new requirement can be found in the 837I and 837P implementation guides.

Medicare Fee-For-Service (FFS) issued an announcement Dec. 14, 2011 regarding its plan for the 90 Day Discretionary Enforcement Period for non-compliant HIPAA covered entities.

Tip: CMS recently published six FAQ items related to the 90-day discretionary enforcement period. These new FAQs can be found on the CMS website.

Source: MLN Matters® Number SE1138

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5 Responses to “For 5010 Compliance, Non-specific Codes Require More”

  1. Larry De Blaay says:

    Are we talking procedure codes NOS or diagnosis codes NOS. I don’t recall seeing an unspecified procedure code.

  2. Barb Wood says:

    I had a situation with an unspecified procedure code in ophthamology with a ‘multifocal intraocular lens’ that was not covered by insurance, unless the patient had a cosmetic rider, so it did not have a procedure code. Make sense?

  3. renee says:

    The transmittal says “procedure” codes.

  4. Gary says:

    How many more inane, esoteric, and downright silly rules can CMS make?

  5. Alaina says:

    Yes procedure codes (CPT and HCPCS). The MLN llink above actually has a link to the complete code set of NOC codes. Another day, another challenge. Good Luck to everyone.

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