ANSI 5010 Claim Format

ANSI 5010 is the newest standard adopted to transmit medical information securely and with as much detail as possible.

Reading this information was never truly meant for human eyes to process, but for quick information it is good to know the basics and you can generally pick out what you are looking for and what you are looking at.

Here is an example claim with two transactions (1 transaction containing an NDC) for one payer/carrier for one patient sent in ANSI 5010 837P format :

(Below the example I will break down what this information is and how it relates to the claim)

((Also note that this information is purely fictional and is pulled from Medisoft's Tutorial Data, any relationship or similarities to actual persons are completely coincidental and unintended))

ISA*00*          *00*          *ZZ*SENDERIDISA06*ZZ*RECEIVERIDISA08*120219*0910*|*00501*000000001*1*P*:

GS*HC*SENDERCODE*RECEIVERCODE*20120219*0910*1*X*005010X222A1

ST*837*0001*005010X222A1

BHT*0019*00*11AAAA*20120219*0910*CH

NM1*41*2*PRACTICE NAME*****46*SENDERID

PER*IC*FIRST LAST*TE*8003334747

NM1*40*2*CCB MEDICAID*****46*RECEIVERID

HL*1*1*20*1

NM1*85*2*HAPPY VALLEY MEDICAL CLINIC*****XX*1234567891

N3*5222 E. BASELINE RD.

N4*GILBERT*AZ*85234

REF*EI*123456789

NM1*87*2

N3*1944 N. KLUGE DR.*SUITE 8381

N4*GILBERT*AZ*85234

HL*1*1*22*1

SBR*P*18*25BB******CH

NM1*IL*1*YOUNGBLOOD*MICHAEL*C***MI*USAA236678

N3*73982 N. 28TH AVE.

N4*PHOENIX*AZ*85044

DMG*D8*19620705*M

NM1*PR*2*U.S. TRICARE*****PI

CLM*17*5007.5***11:B:1*Y*A*Y*Y**OA:EM

DTP*439*D8*20100101

HI*BK:8472*BF:73730*BF:3469

NM1*82*1*HINCKLE*WALLACE****XX*9876543210

PRV*PE*PXC*PROVITAXON

LX*1

SV1*HC:99000:::::HANDLING FEE*8*UN*1***1:2:3

DTP*472*D8*20120219

REF*6R*100

LX*1

SV1*HC:J0490:::::BENADRYL HCL, UP TO 50 MG.*4999.5*UN*1***1:2:3

DTP*472*D8*20120219

REF*6R*99

LIN**N4*12345678901

CTP****50*UN

SE*9999*0001

GE*9999*1

IEA*9999*000000001

FILE HEADER INFORMATION-
This information is normally defined at the clearing house or carrier direct where you are sending the claim file.  Checking for an EDI Companion guide would detail what information needs to be sent here; normally the entire file will be rejected if this information is incorrect.  (In Revenue Manager this information is defined under Configure->Receivers->Header Information &Transaction Set drop-downs)

ISA*00*          *00*          *ZZ*SENDERIDISA06*ZZ*RECEIVERIDISA08*120219*0837*|*00501*000000001*1*P*:	ISA Loop
GS*HC*SENDERCODE*RECEIVERCODE*20120219*0837*1*X*005010X222A1	GS Loop
ST*837*0001*005010X222A1	ST Loop
BHT*0019*00*11AAAA*20120219*0837*CH	ST Loop

Submitter Name & Contact Information

This information will be dependent on the clearing house or carrier direct's requirements; but will normally be the userID or Submitter Number, the contact information is required to be sent, but I have yet to meet someone that has been contacted via this information.  (In Revenue Manger this information is defined under Configure->Receivers->Header Information)

NM1*41*2*PRACTICE NAME*****46*SENDERID	1000A Loop
PER*IC*FIRST LAST*TE*8003334747	1000A Loop

Receiver Name

This information will be the clearing house or carrier direct where you are sending the claim file.  This information will be in the EDI Companion guide normally. (In Revenue Manger this information is defined under Configure->Receivers->Header Information)

NM1*40*2*CCB MEDICAID*****46*RECEIVERID	1000B Loop
HL*1*1*20*1	2000A Loop

Billing Provider's Name & Contact Information

This information will be defined and pulled from Medisoft's Practice information if the rendering provider is set to file claim as group.  Otherwise the individual provider's information would replace the information seen here.  This would relate to the information in Box 33 on a HCFA Paper claim.

NM1*85*2*HAPPY VALLEY MEDICAL CLINIC*****XX*1234567891	2010AA Loop-NM1 Seg
N3*5222 E. BASELINE RD.	2010AA Loop-N3 Seg
N4*GILBERT*AZ*85234	2010AA Loop-N4 Seg
REF*EI*123456789	2010AA Loop-REF Seg

Billing Provider's Pay-To Address Information

This information will be defined and pulled from Medisoft's Practice Information's Pay-To tab.  Because of new requirements with ANSI 5010, a physical address must be sent for the Billing Provider in loop 2010AA and then an additional address can be added such as a PO Box or another separate payment address can in loop 2010AB, if you would prefer not to have payments sent to the Billing Provider's physical address.  Normally the payment address must be on file with both the carriers and the clearing house where you are sending the claim.

NM1*87*2	2010AB Loop-NM1 Seg
N3*1944 N. KLUGE DR.*SUITE 8381	2010AB Loop-N3 Seg
N4*GILBERT*AZ*85234	2010AB Loop-N4 Seg
HL*1*1*22*1	2000B Loop
SBR*P*18*25BB******CH	2000B Loop

Patient and Contact Information

This information will be pulled from the patient's information in Medisoft.  This loop will repeat until all the patients and their claims and transactions have been processed.

NM1*IL*1*YOUNGBLOOD*MICHAEL*C***MI*USAA236678	2010BA Loop-NM1 Seg
N3*73982 N. 28TH AVE.	2010BA Loop-N3 Seg
N4*PHOENIX*AZ*85044	2010BA Loop-N4 Seg
DMG*D8*19620705*M	2010BA Loop-DMG Seg

Claim's Carrier/Payer

This will be the claim's current payer. (ex if the claim has Medicare as primary insurance and BCBS for secondary insurance; if this was the primary claim, this would show Medicare's information, otherwise for secondary claims this would show BCBS' information.)

NM1*PR*2*U.S. TRICARE*****PI

2010BB Loop-NM1 Seg

Beginning of Claim

This is the beginning of the claim for this patient.  Claims will have a transaction limit of 6, so after 6 transactions have been processed a new claim loop of 2300 will repeat if there are more pending transactions for this patient.

CLM*17*5007.5***11:B:1*Y*A*Y*Y**OA:EM	2300 Loop-CLM Seg
DTP*439*D8*20100101	2300 Loop-DTP Seg
HI*BK:8472*BF:73730*BF:3469	2300 Loop-HI Seg

Rendering Provider's Information

This information will be pulled from the Assigned Provider of the claim. (Note: this does not mean the transaction line's assigned provider necessarily; this will depend on how you "Create Claims" in Medisoft; Assigned Provider radio will pull from the Assigned Provider of that Case, where Attending Provider will group and create claims based on the Assigned Provider at the Transaction line.)  This loop will be omitted if the Billing Provider is the Rendering Provider (ex. Provider is filing claim as Individual).  (Note: This NPI would relate to box 24j on a Paper HCFA claim.)

NM1*82*1*HINCKLE*WALLACE****XX*9876543210	2310B Loop-NM1 Seg
PRV*PE*PXC*PROVITAXON	2310B Loop-PRV Seg

First Transaction on Claim

This is the first transaction's information broken down.

LX*1	2400 Loop-LX Seg
SV1*HC:99000:::::HANDLING FEE*8*UN*1***1:2:3	2400 Loop-SV1 Seg
DTP*472*D8*20120219	2400 Loop-DTP Seg
REF*6R*100	2400 Loop-REF Seg

Second Transaction on Claim

The transaction loop will repeat until all the transaction lines on the claim have been processed.

LX*1	2400 Loop-LX Seg
SV1*HC:J0490:::::BENADRYL HCL, UP TO 50 MG.*4999.5*UN*1***1:2:3	2400 Loop-SV1 Seg
DTP*472*D8*20120219	2400 Loop-DTP Seg
REF*6R*99	2400 Loop-REF Seg

NDC Information for Second Transaction on Claim

Additional information, such as the NDC information, will sometimes be added between the transaction entries and will apply to the transaction directly above it.

LIN**N4*12345678901	2410 Loop-LIN Seg
CTP****50*UN	2410 Loop-CTP Seg

File Footer Information

Once all the transactions, claims, and patients have been processed, this information will be added to signify the end of the claim file.

SE*9999*0001	SE Loop
GE*9999*1	GE Loop
IEA*9999*000000001	IEA Loop

National Drug Codes (NDC) in Medisoft (v17)

Along with the 5010 ANSI implementation, many providers are now being required to provide additional information for the drugs they prescribe.  We are going to focus on Medisoft v17+, because even though most of this information can be applied to older versions, only v17+ will has the supported parts which will allow for 5010 ANSI transmission of the NDC.

NDCs are additional codes added to procedures to signify the type, quantity and method of the drug administered.  Matching procedure codes to appropriate NDCs can be a trying process, but we will discuss more about this later in the tutorial.  First we'll start by showing where NDC is applied in Medisoft and then we will go more into how to find the information to fill these locations.

In Medisoft, open a procedure code from the procedure list (Lists->Procedure/Payment/Adjustment Codes->Edit/Create New Procedure Code)

Code 1=the main reference code of this procedure

Description=normally will be the short description of the drug which usually includes (but not limited to) Name/Brand/Type/Dosage

Alternate Codes=optional code sets (helpful if you have a procedure code 1 which may use more than one NDC, setting the carriers required to use Code set 2 or 3 will allow for this situation i.e.. J0490 and MJ0490 use different NDCs however both their code set 2s are set to J0490, the carrier is set to use code set 2 so in billing to the carrier J0490 will appear as the procedure but will use the NDC based on either using code 1 J0490 or code 1 MJ0490)

National Drug Code=sets the default NDC of this procedure

NDC Unit Price=sets default unit price for this NDC

NDC Unit of Measurement=sets the default unit of measurement for the NDC (note requirements for billing may differ from actual drug unit of measurement (i.e. drug may be in mg's but may need to be billed as 1mg=1Unit))

Code ID Qualifier=no longer needed for NDCs (i.e. remove N4 if present)

After these settings have been defined under the procedure code, when it is used in transactions from this point forward the additional NDC information will be added to the transaction lines as defaults for this code.  (Note: if you update an NDC code for a procedure code, you must update the transaction line details of any previously created transaction, if it still needs to be billed, otherwise it may contain the pre-update data or none at all, checking the transaction or claim before it goes out is the safest method for billing)

We recommend you add the NDCCode, NDCUnitCount, NDCUnitMeasurement, NDCUnitPrice, Procedure Description and the transaction Description fields to the transaction entry screen in Medisoft to facilitate adding additional information when entering information through transaction entry.  This information can also be set for the transaction line by selecting the "Details" button, while the line is selected.

For paper claims you may be required to copy the Procedure Description field to the Description (transaction) field, because paper claims require both the NDC and the short drug description in the space above the transaction line on the claim form.

 

For ANSI 5010; Loop2400-SV1 and 2410 will contain the information relating to the procedure code and NDC information.  Which would be similar to the following if the above transaction line information was used:

LX*1

SV1*HC:J0490:::::BENADRYL HCL, UP TO 50 MG.*4999.5*UN*1***1:2:3

DTP*472*D8*20120219

REF*6R*99

LIN**N4*12345678901

CTP****50*UN

We have found one of the most difficult things about billing procedures with NDCs is matching up the correct NDC to bill with the appropriate information.  Below we have listed some of the ways we have found to make this process easier, however in some cases (most, really) you will end up having to bill the procedure w/ code and details to find out if it will pay correctly by that specific carrier.  Different carriers may have different requirements for the Procedure Code, NDC or its additional information, normally you can base the majority of your information on Medicare's requirements but this may not always apply with other carriers.

The first thing is to try to find out as much as you can about the procedure code, the drug you are using and any other information from the carrier you are trying to bill or the Representative/Distributor of the particular drug itself.  This can be tedious, especially if you are just getting started billing out NDCs for a practice that has been billing previously or has a large number of procedure codes that require NDC.  This process, although trying maybe actually faster than the other option which is to bill out and wait for a payment or denial and then possibly have to re-bill with different information.  Majority of the time the carrier is not going to be able to tell you prior to billing the code at least once, in my experience at least.  Check with the carrier or on their site for an HCPCS-NDC-J-Code Crosswalk which would provide you with all the information you need specific to that carriers requirements.  Most do not offer this very helpful tool, but Noridian does and have been keeping it up to date month to month in 2012.

Noridian's NDC-HCPCS Crosswalk -
https://www.dmepdac.com/crosswalk/index.html
 

Or you can use the FDA's NDC search or even download their database information and use that if you wish.
http://www.fda.gov/Drugs/InformationOnDrugs/ucm142438.htm

The FDA NDC Search will normally return the 10-digit NDC, since an 11-digit NDC is required for billing purposes, you can add leading-zeros (ex. 123456789 would be 00123456789)

You can normally find an 11-digit NDC number printed on the drug package in a 5-4-2 format. The first five digits of the NDC identify the drug manufacturer, the next four identify the specific product and the last two identify the package size.   You may be able to use this knowledge to further your search for the correct NDC if the code on the drug package is not the appropriate NDC to bill under the procedure/diagnosis on the claim.

If you can easily find the code/NDC Noridian's crosswalk, use the FDA search to find the drug and then try to find the result on the crosswalk would be the best route to take.

Once the drug is found on the crosswalk, you will have you J-Code, NDC, short description, Unit of Measurement and Unit count.  The unit of measurement and unit count can vary depending on the carrier, however we have found most carriers require the Unit of Measurement to be "Units" and the Unit count to be the amount of "Units" per "transaction/dose".  (ex 50Mg of DrugA=Unit of Measurement will be 'Unit'  where 1Mg=1Unit & Unit Count will be '50'.  The transaction would then have only 1 unit on the 'Units to bill' because the drug dose of 50Mg was only administered once.

The next part will be calculating the Unit Price.  This can be determined by taking the amount you normally charge for this procedure and dividing it by the Unit Count.  (ex. Practice charges $4999.5 for each J0490 procedure they perform.  Since this J-code is administered in 50ml it is equal to 50 Units for Unit Count.  Divide the Unit Price by the Unit Count, 4999.5/50=99.99; so the Unit Price of this procedure is $99.99)

You should check with the Carrier you are trying to bill to or your drug's representative for more information about the Unit Price or anything else discussed in this tutorial not directly relating to Medisoft's data entry.   For any and all other questions you may contact Medical Data Solutions support for more information or training if you would like.

All the information used as examples in this tutorial are purely fictional and any relation to actual medical information or billing is purely coincidental. 

Please use this tutorial's information for reference purposes only!