Insurance News Bulletins

Action Items for the new 5010 edi readiness on January 1, 2012

1. Injections and drugs requiring NDC numbers:

Please add field #57 "Units" in the procedure code dictionary.

Acceptable units are ME ML GM and UN.

2. Add 9 Digit Zip codes to All Physicians and Facility Records.

If you do not know what the extra 4 digits of the zip code is for any address, you can look it up on the USPS website by going to www.usps.com and clicking on Look Up a Zip Code on the left hand side.  There you can enter the address and it will return the full 9 digit zip code.

Note: If your Physicians' ZIP+4 codes are all the same, Type "FIXDRZIP" <Enter> ( without the quotes ) from the main menu for a program that will fix all the zipcodes at once.

Facility Dictionary Example:

3. Eliminate P.O. Box Numbers and Drawer numbers from the address for the above Physicians and Facility Records.

Note: A special PAY-TO address can be setup for P.O. Box Numbers. Please email officemedicine@comcast.net if this is required.

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* End of Tasks for the new 5010 EDI format readiness. *

Frequently asked questions answered:

New ICD-10 HIPAA EDI billing format 5010 questions answered

Q: What is ICD-10 and the HIPAA 5010 billing format?

A: The ICD-10 and EDI billing format 5010 involves changing the diagnosis code to 6 digits, expanding the length of the patient name field, and about 50 other less significant changes to the EDI billing format.  ( Example:  You can't use a "P.O. Box" for the Dr's address )
The real challenge will be to look through the thousands of new ICD-10 codes and substitute these for the current ICD-9 codes if needed. We have a conversion program for this purpose which will automatically convert the old ICD-9, however the selection of the proper new diagnoses are best determined in conjunction with your professional society.

Q: Is Office Medicine Ready for the 5010 EDI billing?

A: If you have version 10.9 or higher, the 5010 format is already installed on your system, but is toggled "OFF" since no payer is ready to accept these claims. Your diagnosis tables/dictionary already accept the 6 digit ICD-10. Testing for 5010 is mandated by BCBS and Medicare and will begin October 2010.  Testing must be completed by year end.

Office Medicine has tested the 5010 format with Medicare and BCBS. - Test results are below:

Q: Will any new computers be required for the ICD-10 or 5010 EDI format?

A: No

Q: Will training or classes be necessary to use the ICD-10 or 5010 EDI format?

A: Probably not, but we are having a series of seminars which will include ICD-10 as a topic.

Here are some of the technical changes required by the 5010 EDI format:

* National provider identifier reporting is fully supported.
* New ICD-10 codes will be fully supported, effective Oct. 1, 2013.
* Use of a post office box as the billing provider address is prohibited.
* A nine-digit ZIP code is required at the billing and service provider loops.
* Assignment or Plan Participation Code (Loop 2300 CLM07) can now be used for providers to accept assignment with payers. Previously, this segment was used to indicate Medicare participation status only.
* Approved and allowed amounts are deleted from AMT segments for COB claims.
* The number of diagnosis codes expands to 12.
* The date-of-service range will only be required when the “from” and “to” dates are different.
* The pay-to-provider address is required when different than that of the billing provider.
 

Billing and reporting for e-prescribe incentives

STEP 1: Did you bill one of the CPT or HCPCS G-codes listed in Table above for the patient you are seeing? NO: You do not need to report this measure for this patient for this visit. YES: Proceed to Step 2.

STEP 2: You should report only one G-code for 2010 (or numerator code) on the claim you submit for this Medicare patient for this visit. • If ANY of the prescriptions generated for this patient during this visit were sent via a qualified e-prescribing system: REPORT G8553 • If NO prescriptions were generated for this patient during this visit: REPORT NOTHING • If ALL of the prescriptions generated for this patient during this visit were printed or phoned in as required by state or federal law or regulations, due to patient request, or due to the pharmacy system being unable to receive electronic transmission; OR because they were for narcotics or other controlled substances: REPORT NOTHING

Note: G8553 must be defined in the procedure code dictionary with a 0.00 Charge amount and the flag "Q" in the flags field.

Claims-based reporting example: Medicare Part B patient A sees Dr. X for an office visit on January 14. Dr. X generates and transmits 3 eRx prescriptions. Dr. X bills encounter code 99215 and submits quality-data code (QDC) G8553 on the claim. Even though Dr. X generated and transmitted 3 eRx prescriptions, this would count as 1 instance of eRx reporting. If patient A returns to see Dr. X January 28 AND Dr. X generates and transmits 2 eRx prescriptions, bills 99212, and submits QDC G8553 on the claim, this would count as 1 instance of eRx reporting.

NDC Drug Codes:

If you are required to submit insurance claims for injections with an NDC number, place the number in field #5 (NDC/Category) in the procedure code dictionary.

The number should be entered as "NDC 12345123412". The letters "NDC" must precede the number, followed by the 11 digit NDC drug code.

PQRI INCENTIVE CODES:

Note: Any PQRI billing code must be defined in the procedure code dictionary with a $0.00 Charge amount and the flag "Q" in the flags field #56.

Modifiers used for PQRI must be added to the National Modifier Dictionary or they will be edited out.

WPS Medicare EDI e-News

Download Local Install Instructions

Click Here to Download the Latest Medicare EZ Print Software

Stop Paper Remittance For Electronic Remittance Receivers

If you receive an Electronic Remittance Advice (ERA), and have been doing so for 45 days, then this article is of importance to you.

The Centers for Medicare & Medicaid Services (CMS) and Wisconsin Physicians Service are interested in and committed to reducing paper. Current paper reduction initiatives include the Administrative Simplification Compliance Act s (ASCA) mandatory electronic submission of Medicare claims (with limited exceptions), web based communications (such as policies, Communiques and Listservs), efforts to increase use of Electronic Funds Transfer (EFT) and the development of Medicare Remit Easy Print (MREP) software that gives providers a tool to read and print remittance advice.

Beginning June 1, 2006, the Standard Paper Remittance (SPR) received through the mail will no longer be available to providers/suppliers who also receive an ERA, whether the ERA is received directly or through a billing agent, clearinghouse, or other entity representing the provider/supplier (CMS Change Request 4376). In response to the provider/supplier communities continued need for SPRs, CMS has developed free software called Medicare Remit Easy Print (MREP) that gives providers/suppliers a tool to read and print a remittance advice (RA) from the HIPAA-compliant Health Care Claim Payment/Advice (835) file. The MREP software was designed to incorporate new functionality to save providers/suppliers time and money. The paper output generated by MREP is similar to the SPR format. CMS has worked with other payers to insure their acceptance of the SPR generated by the MREP software for Coordination of Benefit claim submission. Additionally, CMS has worked with clearinghouses to assure similar software is available to read and print an ERA for those providers/suppliers that utilize clearinghouse services. We encourage providers/suppliers currently receiving the ERA, who don t use software to read and print RAs from these files, to begin using MREP or other similar software before the June 1st cutoff. Please go to http://www.wpsmedicare.com/provider/mrep.shtml for further information regarding MREP software. We appreciate your continued cooperation as the Medicare program moves toward a more electronic environment.

If you need additional information you may also contact the WPS EDI Hotline for IL, MI & WI: 877-567-7261, or for MN: 952-885-2811, 952-885-2881 or 952-885-2882.

QUARTERLY REMINDER TO APPLY FOR A NATIONAL PROVIDER IDENTIFIER (NPI) & ANNOUNCEMENT OF NEW NPI WEB PAGE (Will be repeated until further notice)

Announcing the new CMS web page dedicated to providing all the latest NPI news for Fee-For-Service (FFS) Medicare providers! Visit http://www.cms.hhs.gov/NationalProvIdentStand/ on the web!

While this page is dedicated to the Medicare FFS community, it contains helpful information and links that may benefit all health care providers. Reminder--Health care providers are required by law to apply for a National Provider Identifier (NPI).

To apply online, visit: https://nppes.cms.hhs.gov