May 2009 Newsletter
Future Institutional Billing Requirements Related to the ANSI 5010 837 Implementation
While the implementation of the ANSI 5010 version of the healthcare EDI transactions seems a long way off, 2012 will be here faster than you think. Along with the changes in the ANSI format, there are other subtle billing modifications that may drastically change how you create your UB-04 (Institutional) claims. The elimination of several segments/fields will reduce some of the data sent, while at the same time, new segments/fields are being added that are not even on the hardcopy form. Many of the deleted fields are somewhat obscure and were generally not used anyway, while others were being used. Several stand-alone fields will be moved to other reporting mechanisms, like Value Codes, on the UB-04. Some of the field changes are:
- Responsible Party Name and Address – eliminated
- Payer Estimated Amount Due – eliminated
- Patient Paid Amount – will be Value Code FC
- Claim Day Fields (Cov., Non-Cov., LTR and Coins. days) – will be Value Codes only.
Many additional segments/fields could cause the billing of Institutional claims to get a whole lot more complicated, if implemented by CMS. They include:
- A new Pay-To Plan Name, Address and ID loop – 2010AC loop
- A separate segment for Referral Number (split out from the Prior Auth. field ) – 2300 loop/REF segment
- Rendering Provider Information – 2310D loop
- Remaining Patient Liability – in both the 2320 loop/AMT segment and 2430 loop/AMT segment
- Line Item Control Number (a control number linked to a specific payer line item payment for tracking purposes) – 2400 loop/REF segment
- Physician Information – at the charge line level (Operating, Other Operating, Rendering and Referring physician)
The different segment qualifiers and additional fields mean many changes are in store for the ANSI 5010. Other changes include sending Patient Reason for Visit codes, E-Diagnosis codes and the extra Physician Name/Number fields, as well as the future conversion to ICD10 codes (in 2013). Quadax will, of course, adhere to all requirements to make sure we are HIPAA compliant and use the tools at our disposal to test these new formats. Quadax currently employs the services of Claredi to certify our ANSI formats are compliant with HIPAA mandates. We highly recommend that anyone who utilizes the ANSI 837 internally purchase the final ANSI 5010 version of these specifications from Washington Publishing, and then closely review the specifications so you fully understand what is required to implement this mandated format.