Guest Post: Top 5 potential HIPAA 5010 rejections

Carl Natale
by Carl Natale

The following is a guest post by Jackie Griffin, manager of training and project implementation at Gateway EDI.

Jackie GriffinThe HIPAA 5010 transition date is fast approaching, and the new format will require substantial changes to claims information submitted. Practices that do not make these changes will face rejections and potential delays in reimbursement. Below are a few of the top rejections that could impact claims during the transition to 5010.

Billing Provider Address

HIPAA 5010 requires that a physical address be submitted for the billing provider. P.O. boxes and lock boxes no longer can be reported in this field, and claims containing a P.O. box in this field will be rejected. If your claims still require a P.O. box, it should be sent as the pay-to address. The pay-to address only should be submitted if it is different than the billing provider.

Drug Quantity

If you submit a National Drug Code (NDC) on the line of service for injectable medications, HIPAA 5010 requires that the drug quantity be reported. The unit of measure must also be submitted on the claim file in addition to what you already send on service lines, including the HCPCS code, the total charge and units of service.

Ambulance Claims

In HIPAA 5010, the ambulance pick up and drop off locations are required on all ambulance claims. These were not required on claims before HIPAA 5010.

Anesthesia Claims

In HIPAA 5010, anesthesia services must be reported in minutes rather than units if the procedure code does not define a specific time period. If the procedure code has minutes in its description, the service can be reported in units. When reporting the time period, hours must be converted to minutes. For example, a total anesthesia time of 2 hours would be 120 minutes and should be reported as 120.

9 Digit Zip Codes

The Billing Provider and Service Facility locations require a 9 digit ZIP code in HIPAA 5010. All other ZIP codes do not require the 4 digit extension. If you do not know your ZIP code’s 4 digit extension, you can find it at the U.S. Postal Service’s ZIP code lookup tool.

Your practice should work with your software vendor to ensure your system can accommodate these necessary data changes.

Jackie Griffin is manager of training and project implementation at Gateway EDI, a health care electronic data interchange provider. Get more information, HIPAA 5010 tips and advice.