5010 Billing and ICD10 Coding Conversion

June 2011
Management Home Page 

By Leigh Polk, Director of Marketing and Business Support Services
PSA, LLC


Beginning January 2012, the means by which providers exchange data with payors will change dramatically over the next several years. The changes – upgrading ANSI 4010 to ANSI 5010 and ICD-9 to ICD-10 – are required by a new directive from the U.S. Department of Health and Human Services (HHS).

5010 What You Need to Know
As a part of the industry conversion for professional claims (837) from the 4010 standard to the 5010 standard, there are a number of data reporting changes. The federal deadline for implementing these changes and complying with the HIPAA 5010 financial and administrative transaction sets is January 1, 2012. Improvements in the 5010 transactions include clarified instructions, reduced ambiguity among common data elements used in different transactions, and elimination of redundant and unnecessary data elements.

Some of the changes that have been identified are: 5010 requires the same NPI to be sent for all payers for a single billing provider; 5010 requires the billing provider address to be a street address and not a P.O. Box/Lockbox address (2010AA loop); a new Pay To loop (2010AB) has been added to store remittance addresses, such as P.O. Boxes or bank lockbox addresses, if they differ from the street address of the billing provider address; a 9-digit ZIP code needs to be sent for the billing provider; and for all health plans that assign a unique identifier per member, the patient must be listed as the subscriber.

These new guidelines may require providers to change the way they are credentialed with the payer and also may require changes to their National Plan & Provider Enumeration System (NPPES) information.

CMS National 5010 Testing Day-August 24, 2011
With less than six months until the compliance date, billing providers should be taking steps to ensure compliance, including conducting external testing with payors. To assist in this effort, CMS has scheduled a National 5010 Testing Day to for Wednesday, August 24, 2011 (a repeat of June 15, 2011). This will provide an opportunity to test compliance efforts with the added benefit of real-time help desk support and direct and immediate access to MACs.

ICD-10 What You Need To Know
On October 1, 2013 the health industry is changing from ICD-9-CM to ICD-10-CM for diagnosis coding. In going from ICD9’s 13,000 codes to ICD-10’s 68,000 codes, ICD-10-CM contains a more extensive vocabulary of clinical concepts, body part specificity, patient encounter information, and other components from which codes are built.

For Example: ICD-9 code “599.72 Microscopic hematuria” would be coded in ICD-10 as either “R31.1 Benign essential microscopic hematuria” or “R31.2 Other microscopic hematuria”.

Stated benefits of ICD-10 are: improvements in data, quality, and disease management; decreased need for back-up documentation for claims; and less ambiguity in coding, leading to fewer payer-by-payer differences in interpretation.

How You Can Prepare for ICD-10
• The #1 most important thing pathology practices and laboratories can do now is to ensure you are receiving complete diagnosis information from your referring physicians on every case. This may require both enhancement of your lab intake protocols and education of referring physicians to make certain the clinical reason for each request is properly and thoroughly documented.

• If your practice performs your own diagnosis coding, coding professionals recommend that ICD-10 training take place approximately 6 months prior to the October 1, 2013 compliance date. There are a wide variety of training opportunities and materials available through professional associations. Because of the greater specificity in ICD-10 your coding staff may also require more training in anatomy and physiology concepts.

• Whether your billing provider performs your diagnosis coding or you do it in-house, you should go ahead and identify your current systems and work processes that use ICD-9 codes. This could include clinical documentation, encounter forms/requisitions, contracts (because ICD-10 codes are much more specific than ICD-9 codes, payers may modify terms of contracts, payment schedules, or reimbursement), etc. It is likely that wherever ICD-9 codes now appear, ICD-10 codes will take their place. Consider what you will need to do to update affected processes.

• Remember, if your current requisitions include ICD-9 numeric codes, they will be outdated and unacceptable in 2 years. Review your requisition form to ensure compliance and all necessary information is captured.

PSA provides billing, coding, marketing, and business support services to pathologists nationwide. For more information on PSA, please visit www.PSAPath.com or call 800-832-270 x 2941.