Guest post by Jackie Griffin

On January 1, 2012, providers must switch to 5010, a new standard format for submitting electronic claims information that will accommodate new developments in healthcare and the upcoming ICD-10 code set changes.

The switch from the current 4010A1 format to the new 5010 format requires substantial changes to the claims information submitted. Practices that do not make these changes will face potential delays in reimbursement. Beginning in January, you will need to provide additional information on your claims that was not required in 4010, and the data fields in your claims forms will need to be revised to accommodate new requirements. Here are four examples of data changes that will affect your practice's claims processing in 2012:

• Zip code: In 5010, providers must submit a nine-digit zip code when reporting billing provider and service facility locations. Providers should work with their software vendors to ensure they can capture the full nine digits for the billing provider and service facility addresses.
• Billing provider address: Although P.O. box and lock box addresses were previously allowed in 4010, 5010 guidelines require that the billing provider be listed as a physical address. If a P.O. box or lock box address is necessary for payments and correspondence from payers, it must be reported as a pay-to address. This rule applies to both professional and institutional claim formats. Again, providers should work with their software vendors to ensure that the correct addresses are captured and submitted before the 5010 implementation deadline.
• Billing provider NPI: New 5010 guidelines focus on creating uniform reporting of billing National Provider Identifiers (NPIs) to all payers. Providers who are not consistently reporting the same NPI with all payers may need to reexamine their current billing practices and adjust accordingly. Start by reviewing your billing system to identify what NPI your office sends to each payer. Then, communicate the differences in NPI reporting to those in your office responsible for billing and determine what NPI your office should be using for claims. Once you develop a consist NPI, contact the payers' provider relations offices to verify what steps to take to update your billing NPI with their organizations.
• Anesthesia minutes: In the current electronic 4010A1 format, anesthesia services could be reported as either minutes or units. In 5010, anesthesia services must be reported as minutes. Units may only be reported for anesthesia services when the code description includes a time period or indicates that the time is assigned to a primary code. It's recommended that providers verify that their systems can report only minutes for time-based procedure codes that do not have a time period in the description and remediate the system if needed.

5010 will include many other changes that will increase your potential for claims rejections. The resolutions to some of these data entry changes are rather technical so I encourage your office to work closely with your practice management software vendors and other billing partners to revise claims processing forms now so your practice continues to get reimbursed in a timely manner.

Editor's note: Jackie Griffin is manager of training and project implementation at Gateway EDI. For more tips on 5010, visit www.gatewayedi.com/5010.