Required Fields to Convert to 5010 – Professional Claims (HCFA) Q: Who is considered as a Billing Provider? A: The use of the billing provider field has been clarified. In 5010, the billing provider must be a provider of health care services and can no longer be a billing service or clearinghouse. 4010 to 5010 Change: Billing Provider field can no longer state the information of a billing service or clearinghouse. Information must be that of a health care service provider. Q: Can the Billing Provider address be a PO Box or Lock Box? A: The billing provider address must be a physical street address and can no longer be a PO Box or Lock Box. In ANSI 5010 format, there is a Pay-To address in addition to the physical address if the provider prefers to send payments to another location. This Pay-To address can be a PO Box or lock Box. The 5010 Pay-To address is different than the 4010 Pay-To address. The 5010 Pay-To address will have the same name as the physical address provided. Providers sending 4010 files should change the Pay-To name to match the Billing provider name to be compatible with 5010. The Pay-To address no longer refers to a different person or organization. 4010 to 5010 Change: Billing provider must have a physical address. If using the Pay-To address for PO Box or Lock Box, the NPI or Tax ID must match the Billing provider's NPI or Tax ID or claim will be rejected. Q: What is the requirement pertaining to 9-digit zip codes? A: The provided zip codes in the Billing Provider address, Facility address, and Pay-To address must be a valid 9-digit zip code as stated per the United States Postal Service. To locate your organization's valid 9digit zip code, visit https://www.usps.com/ and Click on the "Look Up a ZIP Code™" Tool located on the left-hand side of the page. 4010 to 5010 Change: 5010 requires a valid 9-digit zip code for Billing Provider address, Facility address, and Pay-To address. Claims submitted without valid 9-digit zip codes in the required locations of the Billing Provider address, Facility address, and Pay-To address will be rejected. Q: Which NPI should be used for Billing? A: Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health care provider’s NPI or its subpart’s NPI is reported in segment NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. 4010 to 5010 Change: N/A Q: Are the Tax ID and NPI required for Billing Provider? A: The Billing Provider may be an individual only when the health care provider performing services is an independent, unincorporated entity. In these cases, the Billing Provider is the individual whose social

Required Fields to Convert to 5010 – Professional Claims (HCFA) security number is used for 1099 purposes. That individual’s NPI is reported in segment NM109, and the individual’s Tax Identification Number (Tax ID) must be reported in the REF segment of this loop. The individual’s NPI must be reported when the individual provider is eligible for an NPI. If a Taxpayer Identifying Number (TIN) of the Billing Provider is used for 1099 purposes, it must be reported in the REF segment of the Billing Provider loop. 4010 to 5010 Change: The Social Security number or TIN will be moved to the REF segment in 5010. A NPI must be reported if the billing provider is eligible for one and will remain in segment NM109 of the Billing Provider Loop. Q: What identifiers can be used to identify providers? A: NPI is the main identifier of any provider loop (NM109). The REF segment qualifiers have been simplified to: 0B = State License, 1G= UPIN, G2 = Provider Commercial Number, LU= Location Number (refer to specifications for each provider loop). Tax ID is no longer allowed on any provider loop except for Billing Provider. 4010 to 5010 Change: All commercial qualifiers will be mapped to G2. Tax ID cannot be mapped to 5010 except for Billing Provider. Q: What is new in Anesthesia claims? A: ANSI 5010 SV104 segment must report Anesthesia time in minutes and not units. 4010 to 5010 Change: Units no longer being used to report Anesthesia CPT Codes. Claims must be reported with minutes to pass processing. Q: What are the changes regarding HI segment for Anesthesia claims? A: ANSI 5010 includes a new HI segment for Anesthesia Related Procedure. If the provider is billing for Anesthesiology and knows the surgical CPT code and the adjudication of the claim depends on the provisions of the code, then the HI segment should be sent. 4010 to 5010 Change: Requirement not in 4010. Office Ally will work with payers if the payers require it. Q: What is required when reporting drugs using a NDC code (Loop 2410)? A: ANSI 5010 requires the CTP line segment to identify the quantity of the drug. This segment is renamed from the ANSI 4010 CTP segment Drug Pricing. Milligram units have been added. 4010 to 5010 Change: CPT segment for NDC codes must be present. The claim will reject if no quantity is given. Q: Can ICD-10-CM Diagnosis Codes be converted from 4010 to 5010? A: 5010 allows either ICD-9-CM or ICD-10-CM codes to be transmitted. ICD-10-CM transition is mandated by October 1, 2013. ICD-10 testing to begin in 2012.

Required Fields to Convert to 5010 – Professional Claims (HCFA) 4010 to 5010 Change: 4010 does not support ICD-10. Q: What codes are allowed for the Release of Information Code (CLM09)? A: The Release of Information Code is the code indicating whether the provider has a signed statement by the patient authorizing the release of medical data to other organizations on file. 5010 defines as: The Release of Information response is limited to the information carried in the claim. 5010 allows only the two following codes: "I" = Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes "Y" = Yes - Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim. 4010 to 5010 Change: Code "A" will be mapped to "Y". Codes "M", "N", and "O" will be rejected. Code "I" and "Y" will map directly to 5010.