12 Most Common 5010-Related Rejections
Provided by GatewayEDI, as published in their newsletter February 23, 2012
Here is a summary of the 12 most common data issues that are causing rejections and reimbursement delays:
1. Billing Provider Address
Guidelines require providers to enter the billing provider as a physical address. If a PO 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 all claim formats.
2. Ambulance Claims
Ambulance suppliers who submit medical transportation claims are required to report the pick-up and drop-off locations for ambulance transport. The number of patients transported in the same vehicle for ambulance or non-emergency transportation services must also be reported. There were previously no designated fields for this information, so you will want to ensure that these fields are added to your claims.
3. Drug Reporting
Professional claims for injectable medications must include additional drug information and qualifiers, such as NDC code, quantity and composite unit of measure, in addition to the Healthcare Common Procedure Coding System (HCPCS) code.
4. Zip Code
Providers must submit a nine-digit zip code when reporting billing provider and service facility locations (click here to determine the 4-digit extension to your standard ZIP code). Providers should work with their software vendors to ensure they can capture the full nine digits for the billing provider and service facility addresses.
5. Anesthesia Minutes
Anesthesia services must now 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.
6. Billing Provider NPI
Guidelines focus on creating uniform reporting of billing National Provider Identifiers (NPIs) to all payers. If you are not consistently reporting the same NPI with all payers, you may need to review your billing system to determine what NPI your office should be using for claims. Once you develop a consistent NPI, contact the payers’ provider relations offices to verify what steps to take in order to update your billing NPI with their organizations.
7. Billing Provider Address Location
The billing provider’s physical address is required. If the billing provider has one NPI and one location, enter the physical address of the office. If you have one NPI covering multiple office locations, report the physical address of the primary office, as identified in the National Plan and Provider Enumeration System (NPPES) and/or enrolled with the payer. Finally, those that have a separate NPI for each office location should report the physical address associated with the NPI being billed and as registered in NPPES. Be sure to check with your payers before making changes to addresses, and look for more on this topic in an upcoming whitepaper from the Workgroup for Electronic Data Interchange (WEDI).
8. Primary Identification Code Qualifiers
Previously, an employer’s identification number or Social Security number could be reported as a primary identifier. Now only a NPI can be reported as a primary identifier.
9. Insured (Subscriber) Group or Policy Number and Group Name
The insured group field is now called the subscriber group; the policy number and the subscriber group name is now referred to as the policy number and the insured group name. You can report only one of these fields in each claim, with preference for reporting the group or policy number if it is available.
10. Health Care Diagnosis Code
You can report up to 12 diagnosis codes per claim, but you can only link four codes to a specific service at the service line level. To accommodate claims that contain more than four diagnosis codes, you can enter additional service lines.
11. Line Item Control Number
Practices are now required to enter a unique line item control number for each line of service for each patient. In addition, payers are required to return the line item control number in the electronic remittance advice (ERA) transaction. This change is helpful because receiving the unique line item control number within the ERA gives you the capability to automatically post by service line.
12. Compound Drug Claims
All individual ingredients that make up a compound prescription must be identified on the claim, and a unique HCPCS must be assigned to each ingredient. The provider will be required to enter separate lines of service for each HCPCS. As with single ingredient drugs, the provider must also include their service line charge for each ingredient, the service line associated units, the NDC number, the NDC drug quantity, and the composite unit of measure.
http://www.gatewayedi.com/blog/2012/02/12-most-common-5010-related-rejections/