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Medicare Fee For Service (FFS) 5010 and 837P

Medicare Fee For Service (FFS) 5010 and 837P. Purpose of Today’s Call. Highlight differences Provide update on Medicare FFS activities Discuss Errata as it relates to 837 transactions and Medicare FFS Emphasis on preparation. What was adopted under HIPAA 5010?.

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Medicare Fee For Service (FFS) 5010 and 837P

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  1. Medicare Fee For Service (FFS)5010 and 837P

  2. Purpose of Today’s Call • Highlight differences • Provide update on Medicare FFS activities • Discuss Errata as it relates to 837 transactions and Medicare FFS • Emphasis on preparation

  3. What was adopted under HIPAA 5010? • Version 5010 of the X12 standards • General Changes • Implementation Guides (IG) are now referred to as Technical Review Type 3 (TR3) • Front matter in guides more consistent across transactions • “Situational” rules further clarified • Ambiguities in 4010A1 rolls corrected (ex “should” replaced with “must”) • “If not required, do not send.”

  4. 5010 and Affected Business Processes • Claims (837 Institutional, Professional, COB, Dental, NCPDP) • Claim Status (276/277) • Claim Payment (835) • Enrollment (834) • Premium Payment (820) • Eligibility (270/271) • Referrals and Prior Authorizations (278) • Claims Acknowledgements (277CA) • Acknowledgement for Health Care Insurance (999)

  5. Differences in 5010 • Billing Provider (2010AA) prohibits use of PO Box • Zip codes (N403) requires 9 digit zip • Added Pay to Plan loop (2010AC) • SBR loops allow for 8 additional iterations • Removed Responsible Party and Credit/Debit card loops (2010BC and 2010BD) • Modification to DTP (Date) segments • Modifications to AMT (Amount) segments

  6. Differences in 5010 cont’d • Expansion of number of diagnosis codes to 12 • HI segment allows for ICD-10 • Added Ambulance Drop off and Pick Up loops • Added Anesthesia Related Procedure HI segment • Added Condition Code HI segment • Added freeform narrative note at line level • Removed Purchased Service loop (2310C), loop sequence restructured and reused

  7. Differences in 5010 cont’d • Added PWK segment in 2400 loop • Deleted Home Oxygen Therapy • CR5 • REF Oxygen Flow Rate • Addition of two new QTY segments for Ambulance Patient Count and Obstetric Unit Anesthesia Count

  8. 837P Errata • The Standards Development Organizations have made corrections to the 5010 and D.0 versions of certain transactions. • The Errata versions replace the Base versions for HIPAA compliance. Per the Federal Register (Vol. 75, No. 197, October 13, 2010, 62684–62686 [2010–25684] found at http://www.access.gpo.gov/su_docs/aces/fr-cont.html) • HIPAA compliance will require the implementation of the Errata versions and the Base versions for those transactions not affected by the Errata. • Compliance with the Errata must be achieved by the original regulation compliance date of January, 2012. • Medicare FFS will implement the Errata versions to meet HIPAA compliance requirements.

  9. 837P Errata • Changed various N4 (City, State Zip) from required to situational • Added Property and Casualty Patient Identifier segment (2010CA) • Changed 2010BA/NM108 & NM109 to situational • Changed situational rule for LIN and added values in LIN02 to capture product number/device identifier • Medicare does not anticipate any impact to 5010 implementation or compliance dates.

  10. 837P Errata Comparison (example) Loop Segment Element Description of change ISA Removed Segment Repeat (had '1') GS Removed Segment Repeat (had '1') GS 08 Version number changed to '005010X222A1' ST 03 Version number changed to '005010X222A1' 2010BA NM1 08 Changed from required to 'Situational' 2010BA NM1 09 Changed from required to 'Situational' 2010BA N4 Segment changed from required to 'Situational' 2010BB N4 Segment changed from required to 'Situational' 2010CA REF New segment added for 'Property and Casualty Patient Identifier' 2330A N4 Segment changed from required to 'Situational' 2330B N4 Segment changed from required to 'Situational' 2410 LIN 02 Additional qualifiers added (EN,EO,HI,ON,UK,UP) 2410 LIN 03 Element name changed to 'National Drug Code or ‘Universal Product Number’ 2420E N4 Segment changed from required to 'Situational' GE Removed Segment Repeat (had '1') IEA Removed Segment Repeat (had '1')

  11. Medicare Implementation of 5010 –Common Edits and Enhancement Module (CEM) • Standardized Claim Editing • One set of edits per line of business • Consistent editing • Consistent results • Standardized Error Handling • TA1 • 999 • 277CA • Receipt, Control and Balancing • Claim Number Assignment

  12. Medicare Implementation 5010 • Up to 12 diagnosis codes • Changes to core processing system • Increase quantity from 999.9 to 9999.9 • NPI validation • PWK implementation (CR 7041) • Medicare Secondary Payer (MSP) balancing edits

  13. Timelines

  14. Are you preparing for 5010? • Start now • Ask your vendor and/or clearinghouse about their plans and timeframes implementing 5010 • 4010A1 to 5010 gap analysis – identify: • New content • Deleted content • Modified content • Impact to business needs • Communicate and coordinate • Test: internally and externally • Know your vendor’s schedule • Know your trading partner’s schedule • Communicate within entire organization to insure all impacts identified early.

  15. Compliance Dates • Compliance deadlines were set per public comments • CMS expects compliance deadlines to be met – no extensions • Success will depend on starting early!

  16. Our Message to you… • Start preparing now! • Work with your vendor and/or clearinghouse. • It is your responsibility to be compliant. • CMS expects compliance deadlines to be met – no extensions. • If you fail to prepare, it will be your business and cash flow that will be affected!

  17. Future EDI ACTs 2011 • These teleconferences are to address your EDI questions. • No reservations are required. • Who should attend? Providers, billing staff, vendors and clearinghouses with Medicare EDI questions. • 2011 calls (all times 1-2:30pm cst): Date Dial In ID • January 13, 2011 800-305-2862 23338581 • March 10, 2011 800-305-2862 23353257 • May 12, 2011 800-305-2862 23353258 • July 14, 2011 800-305-2862 23353259 • September 8, 2011 800-305-2862 23353260 • November 10, 2011 800-305-2862 23353261

  18. EDI Addresses & Numbers EDIMedicareA@WPSIC.comEDIMedicareB@WPSIC.com Medicare Part A Legacy A Medicare J5 MAC Part A & B (multiple states) (Iowa, Kansas, Missouri, Nebraska) WPS Medicare EDI WPS Medicare EDI PO Box 1602 1717 West Broadway Omaha, NE 68101 Madison, WI. 53713 Fax: (402) 351-6188 Fax: (608) 223-3824 Med A Hotline: (866) 734-6656 J5 Hotline: (866) 503-9670 Medicare Part B LegacyMedicare Part B Legacy (Illinois, Michigan, Minnesota, Wisconsin) (EFT) WPS Medicare Electronic Data Services WPS Medicare Electronic Data Services 912 N Pentecost Drive 8120 Penn Ave. S., Suite 200 Marion, IL 62959 Bloomington, MN 55431 Fax : (618) 998-5170 Fax: (952) 885-2899 Med B EDI Hotline: (877) 567-7261 Phone: (952) 885-2811 (952) 885-2881 (952) 885-2882

  19. Resources • CMS 5010 and D.0 Webpage http://www.cms.gov/version5010andD0 • Educational Resources: http://www.cms.gov/Versions5010andD0/70_Medicare_Fee-For-Service_Systems.asp • 5010 Technical Report Type 3 guides: • X12: www.X12.org • Washington Publishing www.WPC-EDI.com • WPS 5010: http://www.wpsic.com/edi/5010-Readiness.shtml • HIPAA Version 5010: Fourteenth National Provider Call January 19, 2011 1:00 – 2:30 cst. Go and register at http://www.eventsvc.com/palmettogba/

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