An Approach to 5010 My Experience Tim Bavosi, HRS

Who is affected by the 5010 conversion? Physician billing Alternate site providers, rehabilitation clinics hospitals; Health plans; Health care clearinghouses Business associates that use the affected transactions, such as billing/service agents and vendors

Timeline Effective Date of the regulation: March 17, 2009 Level I Compliance by: December 31, 2010 Level II Compliance by: December 31, 2011 All covered entities have to be fully compliant on: January 1, 2012

Task at Hand Convert existing 4010A1 claim format to 5010A2 by January 1 st, 2012 Receive, in writing, “approval” status from each payer. Prepare hospital staff for transition to 5010A2. Limit slow or lost revenue due to the conversion process.

Technical changes “Over 99 percent of Medicare Part A claims and over 96 percent of Medicare Part B claims transactions are received electronically using the current versions of the standards X12 Version 4010/4010A1”

Technical Changes Side by Side comparison available on the CMS website: s/Downloads/InstitutionalClaim4010A1to5 010.pdf

High Impact Changes Many field length increases throughout the 5010 file. 2010AB Pay-to-Provider Admitting Diagnosis Code required for all inpatient types. Patient Reason For Visit required for all outpatient types. External Cause of injury, Value Codes NDC Codes from PHA COB should work better Discharge Disposition Required on all Outpatient visits

Provider Name must match NPI# Billing Provider Name: 5010 requires us to standardize our name regardless of payer. End User Impact: None. All 5010 claims will be hard coded to show “XXXXXX” as our official name in the Billing provider loop. If service level NPI numbers are used and they are different, we must submit those claims on their own claim file. It will be required that our NPI numbers and name match as when they were submitted and approved. Variations in the name or the way the name is logged could generate denials and rejections. Implementation Responsibility: Credentialing, Revenue Cycle, in-house MEDITECH EDI resource

Subscriber Definition Change Subscriber Definition Change: 5010 requires us to interpret subscribers differently. End User Impact: Moderate. Prior to 5010, patient information was always reported when the patient is a dependent of the subscriber. The subscriber loop is now used to report the member of the health plan. This means the patient should always be represented as the subscriber. Registration users will need to be educated on how to determine if the patient has a unique member number. This determination must be made by utilizing front-end eligibility software or online eligibility requisitions. In my interpretation, the relationship code will represent the relationship to the guarantor but the subscriber and subscriber ID will now reflect the patient demographics, name and member ID #. * Implementation Responsibility: Admissions Management, Admission Staff, Revenue Cycle and in-house MEDITECH EDI resource.

Basic Testing Model Payer HCIS Approval Status Received

Testing Steps Create a 5010 Shell within your Primary HCIS. Download the 5010 test file from you Primary HCIS. Upload the file to to identify setup errors within the format of the file. Continue this process until you are 100% compliant in Claredi. Sent the test file to the payer. Receive 999 Ack Report from payer. Receive level 2 adjudication report from payer. Make changes based on payer reports and continue to resubmit until Approved for production.

Payer testing process varies Response Times Portals Payer resources Level of their own compliance my be in question

Experience so far… Project manager for 3 Massachusetts Sites Have tested with 5 different Payers including Medicare, MassHealth, Tufts, HSNO and Fallon. Received approval status from Tufts and Medicare using the MEDITECH HCIS.

Resource Requirement Have been spending 8 hours per week per site on 5010 development and testing. Recommend allocating at least 8 per week to focus on the 5010 development. Resource should have experience with the 4010 EDI setup and/or EDI transaction sets.

Get going if you haven’t already! If you haven’t started the testing then you are falling behind. The testing process has been slow. Payer responses are slower than expected. Create a meeting schedule now thru January Stay organized!

Questions? Tim Bavosi,