Medicare Fee For Service FFS 5010 and 837

Medicare Fee For Service (FFS) 5010 and 837 P

Purpose of Today’s Call n n 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? n n Version 5010 of the X 12 standards General Changes n n n Implementation Guides (IG) are now referred to as Technical Review Type 3 (TR 3) Front matter in guides more consistent across transactions “Situational” rules further clarified Ambiguities in 4010 A 1 rolls corrected (ex “should” replaced with “must”) “If not required, do not send. ”

5010 and Affected Business Processes n n n n n 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 (277 CA) Acknowledgement for Health Care Insurance (999)

Differences in 5010 n n n n Billing Provider (2010 AA) prohibits use of PO Box Zip codes (N 403) requires 9 digit zip Added Pay to Plan loop (2010 AC) SBR loops allow for 8 additional iterations Removed Responsible Party and Credit/Debit card loops (2010 BC and 2010 BD) Modification to DTP (Date) segments Modifications to AMT (Amount) segments

Differences in 5010 cont’d n n n n 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 (2310 C), loop sequence restructured and reused

Differences in 5010 cont’d n n Added PWK segment in 2400 loop Deleted Home Oxygen Therapy n n n CR 5 REF Oxygen Flow Rate Addition of two new QTY segments for Ambulance Patient Count and Obstetric Unit Anesthesia Count

837 P Errata n n n 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.

837 P Errata n n n Changed various N 4 (City, State Zip) from required to situational Added Property and Casualty Patient Identifier segment (2010 CA) Changed 2010 BA/NM 108 & NM 109 to situational Changed situational rule for LIN and added values in LIN 02 to capture product number/device identifier Medicare does not anticipate any impact to 5010 implementation or compliance dates.

837 P Errata Comparison Loop 2010 BA 2010 BB 2010 CA Segment ISA GS GS ST NM 1 N 4 REF 2330 A 2330 B 2410 N 4 LIN 2420 E N 4 GE IEA Element 08 03 08 09 02 03 (example) Description of change Removed Segment Repeat (had '1') Version number changed to '005010 X 222 A 1' Changed from required to 'Situational' Segment changed from required to 'Situational' New segment added for 'Property and Casualty Patient Identifier' Segment changed from required to 'Situational' Additional qualifiers added (EN, EO, HI, ON, UK, UP) Element name changed to 'National Drug Code or ‘Universal Product Number’ Segment changed from required to 'Situational' Removed Segment Repeat (had '1')

Medicare Implementation of 5010 – Common Edits and Enhancement Module (CEM) n Standardized Claim Editing n n Standardized Error Handling n n n One set of edits per line of business Consistent editing Consistent results TA 1 999 277 CA Receipt, Control and Balancing Claim Number Assignment

Medicare Implementation 5010 n n n 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

Timelines Target Date Activity Dec 2010 Achieve Level 1 compliance (Covered entities have completed internal testing and can send and receive compliant transactions) Jan 2011 Begin Level 2 testing period activities (external testing with Trading Partners and move into production; dual 4010 A/5010 processing mode) Begin initial ICD-10 compliance activities (Gap analysis, design, development, internal testing) April 2011 Jan 1, 2012 Medicare FFS will implement the Errata versions to meet HIPAA compliance requirements. 5010/D. 0 Compliance Date for all covered entities.

Are you preparing for 5010? n n n Start now Ask your vendor and/or clearinghouse about their plans and timeframes implementing 5010 4010 A 1 to 5010 gap analysis – identify: n n n n n 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.

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

Our Message to you… n n n 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!

Future EDI ACTs 2011 n n 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: 30 pm cst): n n n Date January 13, 2011 March 10, 2011 May 12, 2011 July 14, 2011 September 8, 2011 November 10, 2011 Dial In 800 -305 -2862 800 -305 -2862 ID 23338581 23353257 23353258 23353259 23353260 23353261

EDI Addresses & Numbers EDIMedicare. A@WPSIC. com EDIMedicare. B@WPSIC. com Medicare Part A Legacy A (multiple states) WPS Medicare EDI PO Box 1602 Omaha, NE 68101 Fax: (402) 351 -6188 Med A Hotline: (866) 734 -6656 Medicare J 5 MAC Part A & B (Iowa, Kansas, Missouri, Nebraska) WPS Medicare EDI 1717 West Broadway Madison, WI. 53713 Fax: (608) 223 -3824 J 5 Hotline: (866) 503 -9670 Medicare Part B Legacy (Illinois, Michigan, Minnesota, Wisconsin) WPS Medicare Electronic Data Services 912 N Pentecost Drive Marion, IL 62959 Fax : (618) 998 -5170 Med B EDI Hotline: (877) 567 -7261 Medicare Part B Legacy (EFT) WPS Medicare Electronic Data Services 8120 Penn Ave. S. , Suite 200 Bloomington, MN 55431 Fax: (952) 885 -2899 Phone: (952) 885 -2811 (952) 885 -2882

Resources n CMS 5010 and D. 0 Webpage n Educational Resources: n 5010 Technical Report Type 3 guides: http: //www. cms. gov/version 5010 and. D 0 http: //www. cms. gov/Versions 5010 and. D 0/70_Medicare_Fee-For. Service_Systems. asp n n X 12: www. X 12. org Washington Publishing WPS 5010: www. WPC-EDI. com 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/