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Avoiding Version 5010 Snags
You're not alone in changing your billing to meet new requirements. Follow this advice.
By Sean McKinney, Contributing Editor |
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Retina practices have been struggling to comply with the latest requirements of the ever-evolving Health Insurance Portability and Accountability Act (HIPPA). As of June 30, 2012, Version 5010 Upgrade transaction standards have been required, replacing Version 4010/4010A. The switch calls for minor changes, such as consistent use of the National Provider Identifier and 9-digit ZIP Codes, and significant adjustments, such as ensuring that claims shared by medical practices, payors and clearinghouses are consistently formatted.
"The key to the 5010 Upgrade is to make sure your billing software company is on top of all requirements, small and large," says Rosie Taulbee, a board-certified medical practice management specialist and fellow in the American College of Medical Practice Executives. "If your software company has been doing the necessary advance testing, your practice will face fewer challenges."
Long-term Benefits, but . . .
In the long-term, Version 5010 will represent billing information consistently, be less confusing and accommodate the reporting of clinical data, such as ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes. (See http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-
Simplification/Versions5010andD0/
index.html) Version 5010 will also allow you to distinguish among principal diagnoses, admitting diagnoses, external causes of injury, patient reason for visit codes, length of stays and clinical reasons for care.
For now, though, the new requirements have some doctors seeing red — quite literally. Randy Dhaliwal, MD, FRCSC, FACS, of The Retina Eye Center, Augusta, Ga., says Version 5010 profoundly suppressed his cash flow between January and March of this year. His staff spent many hours on the phone with Medicare Administrative Contractors (MACs) in two states to resolve unpaid claims. "The MACs tried to blame the clearinghouses but the issues appeared to be more with the MACs," he says.
The delayed payment problems were eventually unraveled by Congressional Representatives from CMS, prompted into action by Dr. Dhaliwal's local congressman. "I wonder if other practices are aware that this arm of Congress is available to help resolve major issues such as this," he asks.
Ms. Taulbee says she knows of three payors who have not prepared for Version 5010. "When the representative of one payor was contacted, he wasn't familiar with the term 5010," she recalls. "Payor software wasn't ready to receive claims, even though the practices and clearinghouses were tested and cleared."
Wrong Formats
In some cases, experts say, electronic remittance advice notices (ERAs) customized for Version 5010 have been sent without prior notice and testing. Some ERAs have been sent in both 4010 and 5010 formats, causing disruptive duplicates. Ms. Taulbee notes that CMS has changed what states are required to send for claims, leaving payors, clearinghouses and practices unclear on some issues. "This type of confusion can create significant problems," she says.
She says you should press your software vendor to test each new insurance carrier. "Identify sources of delay and have your insurance personnel communicate and track problems by carrier," she advises.
Dr. Dhaliwal notes that the Version 5010 Upgrade was simply a change in file format. "ICD-10 implementation, required by Oct. 1, 2014, will be exponentially more complex than this change," he notes. "Will the MACs be prepared? Billings that showed no problems during the test phase with the MACs for Version 5010 were rejected when the practices moved to the production phase. We'll need to be very proactive going forward."
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