Published 6/1/2012
Jackie Griffin

5010 – Ready or Not It’s Here!

Recently, the Centers for Medicare & Medicaid Services (CMS) announced it would not take enforcement measures against Health Insurance Portability and Accountability Act (HIPAA)-covered organizations that were not 5010 compliant until June 30, 2012. This is not an extended deadline for compliance, simply a grace period before the agency begins taking enforcement actions.

However, providers may already be experiencing an increase in claim rejections. To minimize reimbursement delays, rejection reports should be monitored for the following potential roadblocks.

Billing provider address
5010 guidelines require providers to enter the billing provider as a physical address. If a post office box or lock box address is necessary for payments and correspondence from payers, it must be reported as a pay-to address. This rule applies to both professional and institutional claim formats.

Drug reporting
In addition to the Healthcare Common Procedure Coding System (HCPCS) code, 5010 professional claims for injectable medications must include supplemental drug information and qualifiers such as National Drug Codes, quantity, composite unit of measure, and prescription number.

Zip code
In 5010, providers must submit a nine-digit zip code when reporting billing provider and service facility locations. Providers should work with their software vendors to ensure they can capture the full nine digits for the billing provider and service facility addresses. (The U.S. Postal Service has developed a tool to determine the 4-digit extension to a standard ZIP code; it can be accessed at

Anesthesia minutes
In 5010, anesthesia services must be reported as minutes. Units may only be reported for anesthesia services when the code description includes a time period or indicates that the time is assigned to a primary code.

Ambulance claims
In 5010, ambulance suppliers who submit medical transportation claims will be required to report the pick-up and drop-off locations for ambulance transport. Reporting the number of patients transported in the same vehicle for ambulance or nonemergency transportation services will also be required. Previously no designated fields existed for this information, so providers will want to ensure that these fields are added to their claims.

Resolving these data entry changes may be quite technical. Medical practices are therefore encouraged to work closely with their practice management software vendors and other billing partners to ensure timely reimbursements. For more details on other common 5010 rejections, visit http://www.gatewayedi.com/5010/faq/

Jackie Griffin is client services director at Gateway EDI. For more information about the AAOS Revenue Management Program, powered by Gateway EDI, visit www.gatewayedi.com/aaos