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Top Five Rejections Related to HIPAA Version 5010

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It has been several weeks since HIPAA 5010 became the required electronic transaction standard, and by now many practices are beginning to see how the many changes are impacting claim rejections. For the past couple of weeks, I have been monitoring trends in claim rejections—specifically looking at ones that are directly related to 5010. As can be expected, there has been an uptick in a number of rejections. Within all of these rejections, five specific ones caught my eye because each one could easily be corrected so practices can avoid such rejections in the future. Here is a quick look at these five rejections and how to prevent them:

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.