Healthcare News & Insights

5010 compliance delayed … again

Here we go again! The Centers for Medicare & Medicaid Services (CMS) has decided to delay the enforcement of the HIPAA 5010 transaction standards for claims processing.

The deadline for complying with the new standards was Jan. 1, and that hasn’t changed.

What has changed is CMS originally said it wouldn’t start initiating enforcement of the new standards until March 31. But now after numerous complaints from providers poured in, stating the conversion was “significantly delaying” claim submission and payment, CMS offered a compromise by extending the grace period.

Now, non-compliant medical practices, hospitals and other healthcare entities have until June 30, 2012, to work out any remaining issues, fix technical glitches and become compliant with the new 5010 transaction standards.

While becoming compliant has been challenging for facilities and their IT departments, HIPAA 5010 is supposed to offer hospitals reduced administrative burdens and streamline their revenue cycle.

CMS predicts that after this enforcement extension is over, 98% of claims submitted at that point will be compliant.

Why’s CMS so optimistic?

It seems that many organizations have been making great strides in achieving HIPAA 5010 compliance and just need a little more time to work out the kinks.

If you’ve already achieved compliance, great. But if you’re still in the process and experiencing some difficulties, here are some things to watch for that could cause your claims to be denied:

  • A National Provider Identifier (NPI) needs to be used, not a tax ID or Social Security number.
  • P.O. boxes aren’t allowed on the claims, a street address is required and a nine-digit zip code is required.
  • A maximum of 12 diagnosis codes can be on each claim, however, each specific service can only have four codes.
  • Any unlisted CPT or HCPCS code must have a code description.
  • A Medicare Secondary Payer (MSP) indicator must be submitted on the primary and secondary claim when Medicare is the secondary payer, and
  • Drug quantity and unit of measurement are required when a National Drug Code is listed.



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