Primary Care Coding Alert

Compliance, payment, and ICD-10 hang in the balances

Are you ready to say goodbye to version 4010/4010A1 for electronic transactions? You'll need to be, starting Jan. 1, 2012, when your practice should be fully functional with version 5010 to comply with the Health Insurance Portability & Accountability Act of 1996 (HIPAA) electronic transaction standards.

Consequence: If you don't have your 5010 glitches worked out by January, you won't be able to submit electronic transactions to Medicare and potentially other payers, as well.

Prepping for ICD-10

Version 5010 lays out the technical electronic standards mandated for HIPAA transactions: claims, eligibility inquiries, remittance advice, and payment data using ICD-10.

The current version -- 4010/4010A1 -- does not accommodate the ICD-10 code set. That's why CMS will require version 5010 for use by all HIPAA-covered entities (providers, health plans, clearinghouses, and their business associates, including billing agents) as of Jan. 1, 2012. Implementing the 5010 form in 2012 gives time for testing and implementation before ICD-10 takes effect on Oct. 1, 2013.

Beware of 5010 Glitches

Experts familiar with the 5010 conversion say you should prepare for several common pitfalls before implementation.

Fix the P.O. box: Under the new 5010 standards, the place of service address (the doctor's practice office location) cannot be a P.O. box. It must be a street address, says Robert B. Burleigh, CHBME, president of Brandywine Healthcare Services in West Chester, Penn. If it isn't a street address, the claim will reject. Fixing the problem is up to you. "The vendor doesn't have control of the provider master list -- the practice or billing company has to make sure that address is a street address," Burleigh says. Your "pay to" address can continue to be a P.O. box, however.

Update patient info: Dig into your claim forms now to ensure that the beneficiary's information is accurate to the letter, or you'll face scores of denied claims with the new HIPAA version 5010. That's because CMS will deny claims with a beneficiary's name that doesn't perfectly match how it's listed on the Medicare I.D. card. Along with the patient's last name, you need to be sure you include suffixes, such as Jr. or Sr.. Additionally, the date of birth you put on the claim form must match exactly what the Social Security Administration has on file.

New remark codes: CMS will use several new error codes on claims once the 5010 version goes into effect. If you use a clearinghouse, you should discuss with them how they'll communicate these errors to you, and how these changes will impact your practice.

Check your ZIP codes: You must include 9-digit zip codes with billing and service facility locations. Five-digit zip codes will not be sufficient.

Think 5010 Even for Non-Medicare Patients

Even practices that don't treat many Medicare patients should know about the transition to 5010.

"Either directly or indirectly, HIPAA Version 5010 will impact nearly everyone involved in healthcare transactions -- providers, clearinghouses, and payers, as well as vendors who provide practice management (PM) systems and other transaction-related software(s)," says Kim Dues, CPC, owner of Mass Medical Billing Services in Dickinson, Tex. "It is mostly a complex technical issue for those on the business and administrative side. Although, if the implementation doesn't go smoothly, it will affect all."