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It's time to get moving with v5010 preparations -- the summer will be over before we know it, and external testing starts on Jan. 1, 2011. That means upgrades have to be complete this fall, which means our last days of summer will include activities such as gap analyses and project plans.
5010 Summer Activities
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Gap Analysis: Identify the differences between current 4010 formats and new 5010 formats, validate system readiness for 5010 and establish goals and objectives for 5010 compliance.
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Migration: Translate 4010 formats to new 5010 formats, establish testing plans and identify departments and users affected by 5010 implementation.
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Testing: Perform thorough testing, including a complete 5010 compliance testing as well as a carrier-specific 5010 testing.
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Training: Prepare workflow change documentation, provide 5010-specific training plans and deliver this training to appropriate staff.
What exactly is changing with 5010?
The updates to EDI transactions for 5010 are definitely improvements that have been long in coming. The updates will make it easier to build EDI transactions and most importantly, support ICD-10. Some of the specific changes are in the following areas:
o Primary and secondary insurances identified, improved service type codes
o Elimination of unnecessary sensitive patient information, greater status detail
o Added Present on Admission (POA) indicators for diagnoses
o Separates diagnosis code reporting and increases diagnosis reported from 8 to 12 (Service Line diagnoses remains at 4 per Procedure)
o National Provider Identifier (NPI) usage clarified
o Anesthesia minutes required versus units or minute usage
o Better consistency between professional and dental claims
o Addition of Medicaid pay to plan data
o Better reporting of COB data, allowing for easier COB submission of non-835 payment data
o Consistency in processing previous payment detail to reduce denials and incorrect payments
o Billing addresses may no longer be P.O. boxes or lock boxes
o Usage rules clarification makes implementation easier
o Improved reconciliation
o Medical policy segment added to deliver information on payment issues
o Improved reporting of interest amounts, discounts and advanced payments
o Improved reporting of non-primary payment
o Clarified claims status codes to reduce ambiguity
o New EDI transaction that may be used instead of 997 (based on payer)
What if my vendor is not ready?
Many of the larger software vendors have made their 5010 updates available. Some vendors will deliver a 5010-only upgrade, but others will provide a larger, more time-consuming upgrade that includes non-5010 features that your vendor may include. If your vendors have not committed to deliver 5010 updates, you need to be the "squeaky wheel" or come up with a contingency strategy. Hopefully, you will not need to switch vendors or use a third-party translation vendor. If your vendor will not be able to meet the requirements, then a vendor change may be required
Meanwhile, there are business process issues that need to be addressed.
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Your project plan and timeline should be developed and staff assignments prepared.
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You should prepare your gap analysis, carefully reviewing changes for necessary updates and organizational changes such as data entry workflows, data collection documents, etc. Review organization-specific data such as edits and conditional logic, and clean up unnecessary items.
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Address NPI remuneration. In the new 5010 rule, Rendering Provider and Service Location cannot be subparts of the Billing Entity; they must be external entities (different TINs). The Billing Provider NPI must be the most detailed level of enumeration based on the organization's NPI strategy. NPI strategies are now to be consistent across payers which may result in re-evaluation of NPI usage and NPI enrollment. This is time consuming and seems to be a component that many providers have not planned for. Roll up your sleeves and put your NPI hat back on.
How many resource hours should my organization allocate to 5010?
The Centers for Medicare and Medicaid Services (CMS) has estimated the effort hours to be approximately 40 percent of the hours for implementing 4010A. In our experience, the first exchange will take 30 percent to 40 percent more resource hours then the subsequent exchanges. If you have a small team, you may want to line up some outside resources to assist. Line them up now since the best people may be committed in January.
Which payer do we start with?
Medicare is the leading candidate because they have indicated they will be ready on Jan. 1, 2011. Check with your other payers as well. Unfortunately, it appears that none of the payers will be accepting test files before Jan. 1, 2011. You should have as many of your payers ready to go on that date as possible.
What are some resources for 5010 information?
WEDI is a good resource. You need to be a member, however. Also, CMS has more information here.
Robyn O'Connell is a senior consultant at Hayes Management Consulting and has more than 20 years of healthcare IT experience, including implementation and user support for EDI.
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