San Francisco, CA (PRWEB) December 13, 2011
January 1, 2012, is the deadline for the required adoption of the new standard for electronic claim transactions, the 5010 standard. The 5010 standard replaces the 4010 standard and is required to accommodate regulatory changes in core billing processes such as claims submission and remission, claim status inquiry, eligibility inquiry and transaction acknowledgement.
It i s easy to be misled or comforted by CMS’s recently announced Enforcement Deadline Extension of March 31. It does not change the 5010 Compliance Deadline of January 1. Many payors, including Medicare, are expected to reject 4010 claims submitted after January 1. The Enforcement Deadline Extension is different from the Compliance Deadline; it essentially means the government will not investigate those who don’t comply with 5010 until April 1, unless a complaint is filed.
If a practice is not ready for 5010, there is very little time left to prepare. What follows is a short background on the genesis of the 5010 standard and some advice for a last minute save.
The Health Insurance Portability and Accountability Act (HIPAA) was enacted by Congress fifteen years ago, way back in 1996. It spawned the HIPAA Privacy Standard (and a zillion Notice of Privacy Practices forms) and the HIPAA Security Standard, both enacted in the prior decade. One facet of HIPAA was a requirement that the Department of Health & Human Services create standards for all “covered entities” (i.e., medical practices, health plans, clearinghouses, etc.) to use when electronically conducting core administrative transactions. The present standard is known as X12 Version 4010/4010A1, or 4010 for short. The 5010 standard is an expansion for the 4010 and will allow for more efficient claims transactions. It can accommodate ICD-10 codes, which are slated to debut in October 2013.
5010 should have no impact on a practice’s clinical operation; it addresses only the practice’s electronic claims transactions.
A few practices still do not file claims electronically and are thus not required by law to comply with the administrative simplification provisions of HIPAA. For instance, Medicare exempts practices with fewer than ten full-time employees from their electronic filing requirement. These practices are not required to comply with the 5010 standard.
Steps to Take Now
Contact the practice management software vendor and/or its electronic clearinghouse to find out what needs to be done to ensure readiness for 5010 by year’s end. This should be done immediately. Vendors will most likely ask for some changes to be made, if they are not already in place, including the following:
The use of a physical address for the billing provider. P.O. boxes and lock box addresses still can be used for payments and correspondence, but a practice needs to make sure a physical address is used for the billing provider. No exceptions.
The submission of a full nine-digit Zip Code when reporting billing provider and service facility locations. These can be found via the United States Postal Service’s Zip Code Look-up Tool (http://ZIP4.usps.com/ZIP4/welcome.jsp). The management system’s provider and location files must include these nine-digit zip codes. All nine digits are to be used in claims submissions.
A practice should work with its software vendors to ensure they can capture the full nine digits for the billing provider and service facility addresses.
A practice will probably learn from their PM vendor that not everyone is 5010 ready, including some payors. Practices will need to submit both 4010 and 5010 claims, depending upon the payor, for an indefinite period. The practice management company and the clearinghouse should be able to answer questions on how this should be done. A practice should be certain that these explanations are clear: the risk for claim rejections remains with the practice. This has been one of the biggest worries that practices have expressed.
A small window still remains for testing, and it is prudent to send test claims prior to January 1. The claim form is, after all, the lifeblood of the medical practice. Failure to be 5010 ready puts a medical practice at risk for seismic disruptions to its cash flow.
About Pulse Systems Inc:
Pulse supports ambulatory physician offices through software that seamlessly integrates clinical, financial and administrative processes into one comprehensive solution. Pulse’s Electronic Health Record (EHR) and Practice Management solutions optimize productivity practice-wide, allowing an organization to provide outstanding care at a lower cost. Pulse has been a force in the industry in the U.S. for over a decade and is strongly supported by its parent company, Cegedim. Contact Pulse at 1-800-444-0882 .
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