Coding and Compliance Upgrade to 5010

Let us talk about the biggest change in medical billing in 25 years. When claim data is sent electronically, it's sent as a series of elements, segments and loops. Read this expert medical billing training article to know more.

An element is just a bit of data. A segment is a category of data. And a segment is subcategory of data. And a loop is a category of data. It's a lot like the outlines you had to do in high school English.

But since so many people are using this particular outline, the loops in segments have to be the same for everyone so that Blue Cross Blue Shield knows that loop 1000A is going to be the patient data. And segment NM1 of loop 1000A is going to be the patient’s name.

An element NM101 of segment loop NM1 of loop 1000A is going to be the patient's first name. The categorizing and naming and formatting of all the loops and segments and elements is what makes up a computer language.

Now, right now, all computers are speaking in a language known as NC12X4010A. HIPAA regulations mandated that everyone has to change to NC12X5010 or just 5010 for short. 4010 does not have sufficient detail to be able to handle ICD-10 and all the other information that carriers are now wanting on claims.

Mar 26, 2019
Duane C. Abbey

Most of this change is going to be invisible to people and physician offices or billing agencies. But there are some important issues that everyone needs to consider to maintain medical compliance.

Your software really should be able to speak 5010 right now. Some programs are charging for the upgrade to 5010, others are not. Several billing programs have decided not to upgrade to 5010. So be sure to call your vendor and ask if the program is 5010 compliant and how much the upgrade will cost.

If the vendor is deciding not to move towards 5010, you really need to be shopping around for a new billing program before the beginning of next year.

The real issue is whether a clearinghouse can transmit and communicate with all of the other computers. So clearinghouses have this year to finish what they call end-to-end testing. That would be receiving the data from you and getting it off to the insurance company in a format that the insurance carrier can read.

Part of the issue here is that several insurance carriers have already said they're not going to be 5010 ready on time. So your clearinghouse has to figure out who those carriers are. And it has to have the ability to transmit to them in 4010 without interfering when the carriers that are going to 5010 on time as per HIPAA rules.

Several clearinghouses have decided not to upgrade to 5010 also. So be sure and call your clearinghouse and ask them if they're testing 5010 or if you need to upgrade your interface to them in any way. Again, if the clearinghouse is not moving towards 5010, you really need to have a new clearinghouse before the end of this year.

As we mentioned there were over 500 changes to the electronic data stream. So the next obvious question is, are you capturing all the data you need to transmit? You need to take a close look at your practices and potentially retrain your staff to get all the information you're going to need.

Many of the data stream changes are background medical coding changes, you won't even notice. The first new segment in the stream is actually a code that simply says, “Yes I'm going to transmit in 5010 language.” That is certainly something your computer should be entering without you having to do anything.

There's also a new segment that identifies a few diagnosis code as an ICD-9 or an ICD-10. Again, that segment should be filled in by your software invisibly to you. But there are some changes that are not in the background.

First off, there is a mandatory change that all facilities will have to have a Zip Plus 4. So if you're using just the regular zip code for any facility, any referring physician or your own office, you're going to need to update those to a Zip Plus 4.

Also if you have an insurance carrier like Aetna’s HMO plans that issues a unique ID number to each family member, the relationship for that insurance is going to be self. It used to be that the policy holder was self and then their spouse would be spouse and children would be children. But it's a unique number to each person in the family then the relationship is now going to default to self.

Other changes are optional. And you may want to check with each insurance carrier to determine who needs what. Of course the easiest way to make sure you're capturing everything a specific carrier is going to want is to make sure you get the additional information on everyone.

There are changes. Some of these changes include separate pay-to rendering and billing provider fields. If your carrier wants all three of those fields, they will only accept PO boxes in the pay-to provider field. Rendering and billing providers have to be street addresses, not PO boxes.

Additional fields were also added to indicate what plan paid on the claim that is potentially subject to subrogation rules. So you can bill the medical plan, accept payments, then file the claim to the auto carrier advising them to reimburse the medical plan when they settle the case.

Many carriers are going to require the date of birth for both the patient and the insured. So that's another a bit of data. You want to make sure your office is just capturing in general.

Well, the changes from 4010 to 5010 will provide sufficient additional claim information and facilitate the electronic process as well as allow room for growth. The major reason this change is necessary is that 4010 cannot handle the ICD 10 codes.

Get ICD-10 training online to ensure a smooth ICD-10 implementation and transition; visit AudioEducator.

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