After our discussion, the editor wrote an article that summarized our discussion and the most common 5010-related problems practices are experiencing, along with the correction to these problems. You can read the full article here to learn more.

Are you wondering how to leverage the new 5010 standard effectively while ensuring your revenue cycle remains healthy?

Join us on Wednesday, February 15^th at 1:00 pm EST, for a complimentary webinar, 5010: The Good, the Bad, and the Ugly. Register Now.

During the one-hour webinar, 5010 expert Ken Bradley, Vice President of Strategic Planning at Navicure, will discuss:

• Where the industry is with regards to 5010.
• How to leverage the additional 5010 information to improve business processes.
• What the most common 5010 errors are and how to address them.

Additionally, participants can earn 1.0 Continuing Education Units (CEU) from the American Academy of Professional Coders (AAPC) by attending the live webinar.

Register today!

*This program meets AAPC guidelines for 1.0 Core A or 1.0 CPCO specialty CEUs. On Demand product requires successful completion of a Post-Test for continuing education units. Granting of prior approval in no way constitutes endorsement by AAPC of the program content or the program sponsor.

• HIPAA 5010 – Understanding Two Important New Requirements. This blog focuses on two changes medical practices must make to their claims submission process to be 5010 compliant: using a physical address as the provider billing address and incorporating nine-digit ZIP codes into billing provider and service facility addresses. While many practices have made these changes, we’re finding that some still need to do so. It’s important to note that technology vendors cannot make these changes for practices; practices must make them on their own.

• How Paper Claims Will Be Impacted by 5010. This blog clears up some confusion that still exists today about how 5010 affects paper-based claims. While most providers filing claims with Medicare and other payers need to be compliant with 5010, those providers or payers who meet certain exceptions to the HIPAA requirements and still file on paper aren’t subject to 5010 requirements. If you’re among those providers, you can continue filing paper claims as always—at least for now.

• 5010: January 1 Compliance Date Won’t Be Enforced Until March 31. This blog discusses The Centers for Medicare and Medicaid Services (CMS) decision to delay enforcement of 5010 requirements until March 31, 2012. Although the extension provides practices the ability to work through the 5010 transition without severe damage to their revenue cycle, it does not move the original compliance deadline. Any claims or bills submitted after January 1, 2012 that are not 5010 compliant will still get rejected, but the delay in enforcement allows practices to resubmit a claim without penalty.

• No Fines for Lack of ICD-10 Compliance, Only Lost Revenue. This blog underscores the importance of preparing for ICD-10 and reiterates CMS’ commitment to the October 1, 2013 deadline. Although there will be no formal fines if a practice is not ICD-10 compliant by the deadline, unprepared practices will not get paid—which is an even bigger hit to revenue!

• Four Common Billing Mistakes – And How to Avoid Them. This blog provides tips and strategies on how practices can improve their revenue cycle process. Specific topics addressed include ensuring thorough insurance verification, supporting coding accuracy, responding promptly to denials, and avoiding insufficient billing.

Were there any additional blog posts that you found particularly interesting last year? Leave us a comment below and let us know which articles you found most noteworthy.

1. No Medicare Secondary Payer (MSP) reason code on a primary claim. In Version 4010, claims only required MSP on secondary claims submitted directly to Medicare. Now, however, healthcare providers must submit an MSP indicator on both the primary and secondary claim when Medicare is reported as the secondary payer. If this information is not included, the claim will be rejected.

2. Lack of drug units when a National Drug Code (NDC) is present. A drug quantity and unit of measurement are required whenever an NDC is listed on a claim. Some clearinghouses and technology vendors will proactively reject claims that have an NDC but don’t have the drug quantity and unit of measurement.

3. No detailed description of an unlisted service. Now in 5010, any claim using an unlisted Current Procedural Terminology (CPT) or HCPCS code must also include the code descriptor or payers will reject the claim. Make sure to work with coders and practice staff to make sure this level of description is used for unlisted codes because this was not required in 4010.

4. ZIP codes are only 5 digits. Addresses for both facilities and billing providers now require a nine-digit ZIP code—this is a distinct change from Version 4010, where only the five-digit ZIP code was required. If you don’t know your nine-digit code, contact your local Post Office or visit www.usps.com. Once you have it, incorporate it into all claims—if needed, reach out to your clearinghouse or practice management vendor to ensure this information is correctly incorporated into your system.

5. Billing provider address is a PO Box. In Version 4010, practices could use a PO Box address for the billing location. With 5010, the “bill to” address must be a physical street address rather than a PO Box or lock box address. Before making any changes to claims, your practice should verify its address information in the National Plan and Provider Enumeration System (NPPES) to ensure address information is up-to‐date and accurately reflects your actual street address.

If your practice does not use a PO Box or lock box, you do not need to worry or make any changes. Changing the way you submit your street address is ONLY necessary if you are currently using a PO Box or lock box address on claims. If your practice uses one of these for your billing address, contact your clearinghouse or practice management vendor to work through this issue.

Although these five codes are causing issues for many practices around the nation, they are not the only rejection reasons that have been on the rise over the last few weeks associated with 5010. The transition to HIPAA 5010 definitely has had some hiccups, but with some due diligence practices can easily overcome these issues. We recommend monitoring and tracking your claims rejections and denials carefully over the next few months. If you notice any unusual trends, be sure to contact your clearinghouse or practice management vendor to uncover the reason for the issues and determine how to prevent them moving forward.

While much of the 5010 transition seems to have progressed smoothly, it’s imperative that practices across the nation carefully monitor their cash flow and bottom line throughout the year to make sure that this trend continues. Spikes in rejections and denials, for instance, can be the first warning signs of problems—and may or may not be related to the 5010 transition.

In addition to checking to make sure your 5010 claims are being correctly processed and paid, there are a number of additional tactics that practices can use to improve revenue in the coming year:

• Verify patient eligibility prior to scheduled visits. Eligibility verification tools offer some of the easiest ways to quickly spot and resolve any potential payment problems. As an added bonus, verification lets you know how much a payer will reimburse for a scheduled service. As a best practice, you can use this information to explain to patients exactly how much they will owe for the appointment.
• Encourage patients to pay off their balances quickly. One simple way to do this is to add incentives or convenience for patients. Many people prefer to pay their bills online, so adding a credit card “bill pay” option to your secure website would work with the habits they have already formed. You could also consider offering a discount to patients who pay their balances in full at the conclusion of their visits—or shortly after.
• Streamline processes throughout the revenue cycle. Make sure you’re effectively managing both claims and remittance processes. Use all available electronic tools to ease your entire accounts receivable (A/R) workflow. This should bring productivity up and days in A/R down.
• Monitor secondary claims. Don’t underestimate the value of secondary claims; those dollars can add up quickly. Take advantage of solutions that help you easily submit and collect on secondary claims—whether electronically or on paper.
• Leverage patient data for new opportunities. Take patient care coordination and management to a new level. If at all possible, mine the data available in your practice’s technology solutions to ensure that your patients are following their prescribed care plans—including receiving all recommended preventive exams and screenings. This simple step helps strengthen your patient care and, simultaneously, helps strengthen your revenue stream.

These are just a few quick tips to ensure a steady and healthy revenue cycle; there are many other items practices can and should do in the New Year. What are your top tips for improving revenue?

• Leverage the key changes in 2012
• Manage the increase in patient financial security
• Successfully participate in the government’s incentive payment programs

To learn more about how your practice can stay as profitable as possible in 2012, click here  to download this webinar.

This program meets AAPC guidelines for 1.0 Core A or 1.0 CPCO specialty CEUs. On Demand product requires successful completion of a Post-Test for continuing education units. Granting of prior approval in no way constitutes endorsement by AAPC of the program content or the program sponsor.

It cannot be denied that the long-term benefits of Version 5010 will help the entire industry become more standardized and will negate many variables in claims submission. After all, the main purpose of 5010 is to standardize the data content in all claims for all payers in healthcare. Over the next few months, as payers and practices begin to leverage the new system, all healthcare organizations are sure to realize 5010′s true benefits.

Since almost every practice across the nation has had to change how it submits claims to payers in some way, you will not be alone in experiencing the benefits and pitfalls of 5010. For those who have tested and worked with their vendors and clearinghouses, the transition should be relatively smooth. However, that does not mean that you should not anticipate a few glitches with the new electronic format – there are always glitches when implementing a new system.

Personally, I recommend that all practices carefully monitor claim rejections and denials over the next few weeks as a way to spot possible glitches with the transition to 5010. These two metrics can be the first signs of problems with your practice’s revenue cycle, and changes in these indicators can clue you in that something is amiss.

Should your practice see a drastic increase in the level of rejections or denials, reach out to your clearinghouse vendor and/or the payer directly to get to the bottom of the issue. Don’t wait and hope someone else will notice and fix the problem. Such delays can cost you significant funds.

Now that 5010 is truly underway, your practice can turn its attention to other changes ahead, such as preparing for ICD-10. Along with preparing for ICD-10, you may want to also consider using 5010’s anticipated benefits to work on improving your revenue by eliminating paper from your entire revenue cycle, or taking advantage of the ability to electronically submit claims for secondary insurance.

There are two ways RACs typically identify overpayments. The first takes an automated approach where the contractor uses proprietary software to find unambiguous instances of overpayment. This approach doesn’t include a medical record request.

The more complex method involves requesting medical records and reviewing your documentation and coding to determine whether an overpayment was made. While RACs are limited to the number of medical records they can request during a specific time period, the volume of records can be quite significant depending on the number of physicians in your practice.

Should a RAC decide your practice was overpaid for a claim, they will recoup the excess funds. Although you do have an opportunity to appeal this decision, the appeal process can be equally time consuming and onerous. So the key to making a RAC audit as unobtrusive as possible: don’t be caught unprepared.

To best prepare for RAC audits, you first must overcome your fears and proactively create a specific process for responding to medical record requests. This may involve designating a full- or part-time staff position to oversee the effort—including gathering, photocopying, and mailing any paper-based medical records.

Consideration should also be given to how to best tackle the appeals process if a RAC audit finds overpayments you’d like to challenge. In some cases, appealing may not be worth the time or money, but in others it may be justified. For example, if an overpayment decision relates to a procedure or treatment your practice does frequently, it may be worth appealing—not only to overturn the specific overpayment, but to prevent similar overpayment decisions in the future.

Just as with almost any audit, your ability to justify medical necessity is crucial during RAC audits. According to the Centers for Medicare and Medicaid Services (CMS), lack of medical necessity justification is a common reason for overpayment decisions. More often than not, however, the only real problem is that the provider didn’t sufficiently document why the treatment was appropriate. To avoid overpayment decisions, you must make sure your documentation: 1) is comprehensive, and 2) fully illustrates medical necessity.

A good way to ensure this is to regularly conduct internal documentation audits for each physician in your practice. They don’t have to be expansive—even reviewing 10 records per year per physician can help you discover documentation issues and put corrective plans in place. The more your documentation reflects the reasons behind a medical decision and treatment plan, the more likely you are to avoid costly overpayment decisions.

For further information on the RAC program and how it could affect your practice, go to www.cms.gov/rac.

The first of these activities is verifying insurance. While this may seem like a self-evident step, many practices neglect to perform this critical task—and for understandable reasons. Many practices simply don’t have the staff resources for what too often is still a manual chore. If they do perform it, practices often wait until the patient is standing at the front desk.

Practices should be collecting patient demographics and insurance information over the phone prior to the appointment date. Then, to further streamline verification, practices should automate the process. This allows front office staff to batch verifications, get the relevant information, and focus more closely on those patients who are flagged by the system.

By contacting the patient early, you can verify insurance ahead of time and uncover any problems before the patient walks through the door. This process not only smoothes the registration process, but also prevents claim denials on the back end. (Plus, patients don’t have the anxiety associated with finding out after the fact that a service isn’t covered.)

The second critical activity is posting charges on the same day as the patient visit. The sooner you post charges, the sooner your practice gets paid. Ensuring timely charge posting means working with physicians and coders to educate them on the importance of being prompt—as well as how to design an efficient charge posting process.

Finally, practices should bill every day. Again, this may seem like an obvious task, but there are still many practices that only bill once or twice a week. With the advent of electronic billing, there is no excuse for delayed billing. Payers such as Medicare regularly turn payments around quickly; the faster you submit bills, the faster you get paid.

Bottom line—you should be billing every day your practice sees patients, posting charges immediately, and verifying eligibility upfront. These three things will reduce days in A/R and ensure a more steady cash flow for your practice.

These are just three steps to help your bottom line. What other tactics has your practice employed to improve your revenue cycle?

At the start of this conversation, we focused on how this transition would impact everyone in the healthcare industry. It was the coders, though, that quickly became the focal point of our discussion. Specifically, we talked about the types of questions coders should be asking when preparing an ICD-10 transition plan. These questions include:

• Can the practice’s software solutions or clearinghouse accommodate ICD-10?
• When can the practice begin to send test files that include ICD-10 values?
• Do physicians understand that ICD-10 is not simply a technology update? For example, do they know how codes and documentation requirements will change?

Even if some of your vendors or internal staff cannot answer all of these questions right now, asking them to think about it is still beneficial because they will start to think about the answers. And the sooner you get answers to those questions, the sooner you can start to develop a plan for transitioning to ICD-10. If you would like to learn more about the questions you should be taking and strategies you should be considering to prepare coders for the transition, read this article titled “Tick, Tick, Tick” where I, along with other industry leaders, discuss tips for a successful transition.