Updates

Preparation for 5010

All electronic healthcare transactions (such as claims, ERA, and eligibilities) are transmitted in compliance with standards set forth by The Health Insurance Portability and Accountability Act (HIPPA) and the United States Department of Health and Human Services (HHS). The rule establishes that all covered entities should begin testing and migrating to 5010 during the 2011 calendar year in preparation for the final compliance date of Jan 1, 2012. Beginning on Jan 1, 2012, all electronic HIPAA transactions must be exchanged using the new 5010 standards:

Our billing software will be updated with version of 11.1 which supports the 5010 formats.
This will occur on our development system (which is a mirrored system of current information) to ensure that current claims are not affected until all testing approved and in production.
Once the greenlight is achieve the updated will be transferred to our live system for real time production.

The benefits associated with ANSI 5010 include:

Support of ICD-10 diagnosis codes
Correct deficiencies that are found within the current 4010A transaction sets
Standard definitions of situational data content, which minimizes unique payer requirements
Clarified National Provider Identifier (NPI) instructions
Improved Coordination of Benefit (COB) information within transactions
Enhanced eligibility responses

Readiness with ICD-10 for Jan 2012

Mandatory webinars will be held throughout 2011, during which:

Coders will be training in ICD-10 coding including crosswalks.
All billing staff will be versed in ICD-10 and the impact it will have on the billing cycle

Anticipated benefits from adoption of the ICD-10 code sets include:

More accurately defined patient services
More specific diagnosis and treatment information
More comprehensive reporting of quality data
More accurate payments for new procedures with fewer rejected claim

Impact of the More Stringent Review Criteria

The more stringent review criteria for review of claims selected for the November 2009 report resulted in increases in the error rates due to:

Records from the treating physician not submitted or incomplete
In the past, CERT would review available documentation, including physician orders, supplier documentation, and patient billing history and apply clinical review judgment. Now, CERT requires medical records from the treating physician and does not review other available documentation or apply clinical review judgment.
Missing evidence of the treating physician's intent to order diagnostic tests
In the past, CERT would consider an unsigned requisition or physicians' signatures on test results. Now, CERT requires evidence of the treating physician's intent to order tests, e.g., signed orders, progress notes.
Medical records from the treating physician did not substantiate what was billed
In the past, CERT would review available documentation, including physician orders, supplier documentation, and patient billing history and apply clinical review judgment. Now, CERT requires medical records from the treating physician and does not review other available documentation or apply clinical review judgment.
Missing or illegible signatures on medical record documentation
In the past, CERT would apply clinical review judgment in considering medical record entries with missing or illegible signatures.
Now, CERT disallows entries if a signature is missing or illegible.

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