5010 claims demand new, more specific information

April 25, 2012

The new Version 5010 claim format is designed to facilitate greater specificity in claim reporting, the AOA Clinical & Practice Advancement Group (AOA-CPAG) noted. All claims for services provided after March 31, 2012, must comply with Version 5010.

Practicing optometrists should contact their billing partners to be sure they will be Version 5010 compliant before the deadline, the AOA-CPAG emphasized.

Those billing partners may include claims submission services, electronic health record software developers, and claims clearinghouses.

The 5010 format was primarily developed to accommodate International Classification of Disease, Tenth Edition (ICD-10) codes, which will allow for more detailed reporting of both diagnoses and treatments. However, the new software will go into effect well before ICD-10 implementation and will require health care practitioners and institutions to take a number of additional steps to more specifically identify health conditions and health care services.

The 5010 software format will also require better identification of health care institutions, practitioners, and product suppliers. Optometrists, like other health care practitioners, will have to be vigilant in providing all of the information required under the new 5010 format to avoid claim rejections, AOA-CPAG noted. The AOA-CPAG offers the following tips for successfully filing claims in the 5010 format:

  • Billing provider street address – not P.O. boxes – The billing provider address on claims must now be a street address – not a post office box (Practitioners can still use a P.O. box or lock box to receive payments or correspondence from payers as long as they report the box number as a “pay-to” address.)
  • Nine-digit ZIP codes – Providers must now submit a full nine-digit ZIP code for billing provider and service facility locations. An easy way to determine the four-digit extension to a standard ZIP code is to look it up on the U.S. Postal Service’s ZIP Code Lookup Tool, which can be accessed at http://ZIP4.usps.com/ZIP4/welcome.jsp.
  • Diagnosis codes on all claims – Diagnosis codes are now required on all claims. The maximum number of diagnosis codes has been increased from eight in Version 4010 to 12 in Version 5010.
  • National Provider Identifier (NPI) – Only NPIs can be used as the primary identifier for the billing provider. In the past practitioners have been allowed to report an Employer’s Identification Number (Tax ID) or Social Security Number (SSN) as a primary identifier for the billing provider.
  • National Drug Codes (NDC) for pharmaceutical injections – Professional claims for injectable medications now must include identifiers such as a NDC, the quantity of the drug administered and the composite unit of measure used. Until now, practitioners have submitted a Healthcare Common Procedure Coding System code as the service-line procedure along with the total charge and units of service. Practitioners 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, practitioners must add zeros at the beginning of the segment.

Practitioners should work with software vendors to ensure all of the information required under the 5010 format is provided in required manner in the fields on claim submissions. They should also consider staff meetings to ensure office personnel are familiar with the 5010 format.

Practitioners should also be aware the transition to the 5010 format is widely expected to result an increase in claim rejections, AOA-CPAG noted.

Practitioners should monitor rejection reports and remittance advice closely over the coming weeks. In the event of 5010-related rejections, practitioners should contact insurance carriers or billing services promptly, AOA-CPAG advised.

For additional information on the new 5010 claim format, see the AOA website ICD-10 page (www.aoa.org.ICD-10).

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