5010 Transition: Three tips to smooth out your HIPAA 5010 transition

by: Lauren C. Williams

Published Feb 1, 2012

With the whirlwind of changes regarding the industry switch to HIPAA 5010, you must make sure your practice can comply quickly with as few hiccups as possible.

5010 refresher:You now have until March 31 to get your practice ready for 5010 without being penalized, but only if you submit a transition plan to CMS within 30 days of notification. CMS is also giving providers who have successfully tested 30 days from MAC approval to send all live production claims in 5010.

Heed these three key moves your practice must make to ensure a quick and smooth transition to 5010:

1. Start testing or sending all claims in 5010 now. Keep pushing to get your practice into 5010 compliance despite CMS holding your claims for 10 days and HHS’ 90-day enforcement delay ending March 31, experts say. The 10-day delay pertains only to the fee schedule update and has nothing to do with 5010, says Stanley Nachimson, a former CMS technology expert who now runs his own consulting firm in Reisterstown, Md. CMS accepted test claims during the hold which ended Jan. 17, Nachimson says. If you’ve already tested with CMS and are approved to send 5010 claims, start sending all of your claims in the new format, he says.

Note:The claims hold could pose an issue for providers who started sending live 5010 claims Jan. 1 since you won’t know until later in January if there are problems with your claims, says Robert Tennant, senior policy advisor for the Medical Group Management Association (MGMA) in Washington. However, if you’ve already tested then any denials you get should not be a result of the 5010 format.

Once you’ve transitioned to 5010, check your claims rejection rates to see if they are higher than they were with 4010, Nachimson says. If so, you need to contact your payers to make sure your claims are being submitted and processed correctly.

2. If you haven’t tested in 5010, prepare and submit a convincing transition plan to CMS.

Start documenting everything you’ve done to switch to 5010 in the last year or at least past few months, Nachimson says.

Remember:You only have 30 days from the date your Medicare Administrative Contractor (MAC) notified your practice to submit a transition plan to get it in to CMS. Your transition plan hinges on detailed documentation which must show:

The provider understands any and all changes required for 5010.

A dated list of communication the practice has made with clearinghouses and payers, including CMS.

Any plans or dates of scheduling for testing, Nachimson says.

Note: Simply writing: “I’m waiting on my vendor,” will not suffice as a transition plan. If you are waiting on your practice management system (PMS) vendor to make the necessary updates, list the dates your practice called the vendor and what you discussed during the call.

Example: Oct. 13, 2011, practice manager called vendor, spoke to Mary, was informed that first updates would be completed by Thanksgiving.

Your transition plan will be more of a list than a narrative of what you’ve done to get ready, Nachimson says. Also, be sure to include your anticipated implementation date.

3. Know how 5010-ready your clearinghouses and private payers are. Find out if the clearinghouse has received a letter from your MAC, whether or not it needs to submit a transition plan to CMS and if there is anything your practice needs to do, Tennant says. ”Don’t assume everything is automatically taken care of”, he adds.

Important: Keep tabs on the 5010-readiness of all your private payers to make sure they will be ready by March 31, Nachimson says. You must also check in with your private payers to see if they are accepting 4010 claims, for how long and under what circumstances, Tennant says. Some commercial payers may not accept 4010 and few have announced in any form that they are or aren’t taking these claims, Tennant says.

4 HIPAA 5010 requirements that could stall your claims

Don’t forget these small changes that could get your 5010 claims rejected:

1. Use a physical billing address instead of a P.O. Box. All 5010 claims require a physical street address in the billing provider address field, Loop 2010AA (APCPS 10/2011).
2. Only input a nine-digit ZIP code.You must use your full nine-digit ZIP code instead of the usual five-digit code, Nachimson says.
3. Show proof of patient permission to release. Billers have to show proof that the patient authorizes the electronic release of their data on each claim. Verify your group is covered by an assignment of benefit form at each location the provider(s) work at or you have the patient sign a specific form provided by your group.
4. Indicate Medicare participation. Providers must denote whether or not they are enrolled with a payer on every claim they send.

One final word on reporting anesthesia services: You will need to report a surgical code with anesthesia code 01999 (unlisted anesthesia procedure), the American Society of Anesthesiologists reports. The X-12 Committee is working to finalize language for this requirement (APCPS 12/2011).

Official Resource:

ASA Washington Alert Dec. 22, 2011

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Editor:  Philip Blann (pblann@anesthesiabilling.com).