WEDI Strategic National Implementation Process (SNIP) s and Code Sets Workgroup 837 Subworkgroup Interim 837 s Issue Brief s for ASC X12 837 s: Version 005010 to 006020 TM 4/9/2015
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CONTENT Disclaimer I. Introduction II. III. Purpose of this Issue Brief Scope IV. s in ASC X12 837 s from 5010 to 6020 V. Conclusion VI. Acknowledgements
I. Introduction As part of their normal standards development process, the Accredited Standards Committee X12 (ASC X12), continues to update their standards on an ongoing basis. These updates are not to be used until the Department of Health and Human Services (HHS) adopts them as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) standard through regulation. The last adopted version was Version 005010 ( 5010 ), which continues to be used today as required. A subsequent version of the ASC X12 Insurance Subcommittee (ASC X12N) transactions, Version 006020 TM ( 6020 ), was developed and released for public comment, but was not brought forward for adoption under HIPAA. ASC X12N is currently working on the next version of transactions after 6020 TM. Version 6020 will be the starting point for the next version and will be updated to reflect new requirements for transactions. Members of the industry have expressed interest in understanding changes that have been made to the health care claims transactions between versions 5010 and 6020. Providing information on these changes will give organizations an opportunity to assess the potential future system changes they may need to make when the next version of the standards is adopted under HIPAA. NOTE: VERSION 5010 OF THE TRANSACTIONS REMAINS THE ADOPTED VERSION FOR USE. NO CHANGES TO THE CLAIM TRANSACTIONS NEED TO BE MADE UNTIL A NEW VERSION OF THE TRANSACTIONS IS ADOPTED THROUGH REGULATION UNDER HIPAA. The current HIPAA adopted transactions that must continue to be used are: Version 5010 X222A1 Health Care Professional (837) Version 5010 X223A2 Health Care Institutional (837) Version 5010 X224A2 Health Care Dental (837) II. Purpose of this Issue Brief The purpose of this issue brief is to provide information on changes made in the ASC X12N health care claim transactions between versions 5010 and 6020. These changes may indicate potential future system modifications. Organizations may wish to use the information provided in this issue brief for internal review and planning. They can also use this information to better understand why changes were made in the ASC X12N version 6020. These changes are expected to remain in future versions that may be adopted under HIPAA. Note: The purpose of this issue brief is not to duplicate any change logs that will be developed by ASC X12. III. Scope This issue brief is limited to the following ASC X12N Technical Reports: Version 5010 X222A1 Health Care Professional (837) Version 5010 X223A2 Health Care Institutional (837) Version 5010 X224A2 Health Care Dental (837) Version 6020 X259 Health Care Professional (837)
Version 6020 X260 Health Care Institutional (837) Version 6020 X261 Health Care Dental (837) The changes identified in this issue brief are limited to those in the health care claim transactions between the HIPAA-adopted version 5010 and ASC X12N public comment version 6020. Not all changes between versions 5010 and 6020 of the claims transactions are included in this issue brief. The changes included are the ones that the WEDI 837 Subworkgroup identified as having a potential impact on organizations.
IV. s in ASC X12 837 s from 5010 to 6020 Billing Address Billing And Service Facility Location Relaxed requirement for 9-digit ZIP code for Billing and Service Facility Location Reason for It was determined that not all addresses have a 9-digit ZIP code, so the requirement to report a 9- digit ZIP code was relaxed. Potential Future System s s will need to remove any defaults currently in place to satisfy the 9-digit requirement. s with a 9-digit ZIP code will need to understand from their payers how claims will be handled if they are submitted with a 5-digit ZIP code. Will claims be rejected? Pay-to Factoring Agent Billing New loop Reporting of this information was added based on the business model in which an entity takes over the collection management of claims from a payer. This entity needs to be identified separately in the claim, when applicable. Payers, clearinghouses, validation software vendors, and other organizations that edit and accept claims will need to review their edit rules for when to require a 9-digit ZIP code or allow a 5-digit ZIP code. They will also need to update any necessary programming and instructions for providers on reporting of ZIP codes. s will need to be able to accommodate reporting this information, when necessary. This business model is currently seen more frequently in the property and casualty area.
Diagnosis Pointer Increased the number of diagnosis pointers that can be reported at the service line Reason for A need was identified to be able to point to up to 12 diagnosis codes at the service line level. will decrease the need to split claims when more than 4 diagnosis codes need to be pointed to for a service line. Potential Future System s senders and receivers of claims will need to update their systems to accommodate up to 12 diagnosis pointers at the service line level. The 1500 claim form will continue to only allow 4 diagnosis pointers, so the paper form and will be out of alignment for this data. Agreement Code Data was removed in 5010, but added back in 6020 A need was identified to add back the reporting of a Agreement Code to identify when a non-participating provider is submitting a participating claim. The 1500 claim form uses alpha characters for the diagnosis pointers and the uses numbers, this means that additional mapping is needed for converting the paper form to the and vice versa. The will not be changing from numbers to alpha characters. senders and receivers of claims will need to update their systems to accommodate reporting of this data. Medicare Assignment Code Situational note changed in 6020 limiting reporting requirements Definition was changed between 5010 and 6020 A note has been added to say this data is not reported in claims bound for Medicare. In 4010, this element applied only to Medicare. d in 5010 to apply to other payers beyond Medicare. The situational note has been changed back in 6020 to apply only to Medicare claims. More notes have been added to the TR3 on its usage. Senders and receivers will need to review and update their mapping of the data element. See Other Insurance Coverage for additional information on how to report this value on COB claims.
Predetermination New in the 837I and TR3s 837I Reason for Added an indicator to identify that the transaction is a predetermination request vs. claim being submitted for payment. Potential Future System s The addition of this to the and 837I does not make it a HIPAA mandated business function that must be supported by payers. Original Creation Date Added new segment to the claim to carry the actual date the claim was created out of the provider system Predetermination transaction was a separate TR3 in 5010. Added to help with establishing timeline of claim creation. their systems to accommodate this data, if allowed. their systems to add this information. s will need to make sure they are creating this date when they submit a claim. Downstream trading partners will need to carry this date forward in later processing. Set Creation Date Header Removed note stating that this date is submitter creation date Problems were identified with the use of this element, which were addressed by adding the original claim creation date. Date was being overlaid by trading partners for the date they transmitted the claim out of their system, which then impacted identifying the original creation date. If claim is dropped to paper at any point in the processing, then date would be lost. Senders other than the original submitter and receivers will need to update their systems to accommodate this change. Needed to address the date generated during the various hops and which one to use to establish timely filing.
Procedure Modifiers Procedure Modifiers Tooth Numbers Line Adjudication Expanded number of modifiers that can be reported per procedure code from 4 to 8 Expanded number of modifiers that can be reported per procedure code from 4 to 8 Added the ability to report tooth numbers Reason for A need was identified to send more than 4 modifiers per procedure at the line level. In 5010, additional extra modifiers beyond 4 are being sent in the notes. Was added to provide consistency with the information. A need was identified to report tooth numbers for procedures that are billed on the instead of the 837D. Potential Future System s Updates will need to be made to current edit logic to address not being able to send a 5 th modifier without a 4 th, etc. Senders will need to update their systems to be able to send more than 4 modifiers. Receivers will need to update their systems to accept more than 4 modifiers. Updates will need to be made to accommodate the COB line adjudication information explaining what was paid on. Updates will need to be made to current edit logic to address not being able to send a 5 th modifier without a 4 th, etc. Family Planning Indicator d from situational to required A work-around solution was developed for reporting tooth numbers in 5010. made to comply with ASC X12 semantic note for the yes/no condition or response code. Previously only populated for Yes and will now need to be populated for yes and no EPSDT d from situational to required made to comply with ASC X12 semantic note for the yes/no condition or response code. Previously only populated for Yes and will now need to be populated for yes and no
Purchased Service Amount Drug al Remark Codes Service Adjustment Line Adjudication Other Subscriber and Line Adjudication Removed the purchased service information and added an amount element for reporting the data Added the ability to report additional drug service and adjudication information at the service line level New data elements added to allow for reporting of informational remark codes not associated with Adjustment Reason Codes (CARC) Replaced line adjustment (CAS) with service adjustment information (RAS) Reason for The data reported in the purchase service information segment was not needed except for the dollar amount. The segment was removed and ability to report the purchased service amount was added in an element. Two segments were added to report additional drug information for drug rebate programs. The requirements within the segments align with the current NCPDP Telecommunications Standard Implementation Guide. was made to align requirements with the Health Care Payment/Advice (835). Enabled the ability to link the CARC with the Reason and Remark Codes (RARC). Potential Future System s Will impact COB claims. Will have issues with accommodating RAS if translating a 6020 837 to a 5010 837, because there is no place for the RARCs to be reported.
Secondary Identifiers Loops And Removed qualifier Commercial Number (G2) and added Identifier (A6) Reason for A need was identified to have a more generic qualifier for all payer assigned identifiers. Potential Future System s Condition Codes Dental Readiness Classification Code Billing Secondary Identification in the Payer Loop added 837D HI segment (Qualifier BG) New REF segment added Payer ID Payer d from Required to Situational Assigned Identifier d implementation name from Patient Control Number to Assigned Identifier. d maximum character length from 20 to 35. 837D Reporting of this information is specific to worker s comp claims. Added for TRICARE Active Duty Dental Program Required for claims, not predeterminations. Provided a consistent location of the payer ID within the 837 transaction. To provide clarification on the intended use of this data element.
Admission Date Modified the situational rule to allow at the sender s discretion. Reason for To provide clarification on the intended use of this segment. Potential Future System s Principle Diagnosis Code Qualifier Sales Tax Amount d wording from inpatient medical visits to inpatient hospital services Removed qualifiers ABK (ICD-10) and BK (ICD-9) from Health Care Diagnosis Code HI Segment Removed this AMT segment Eliminated because diagnosis codes are reported in the order of importance based on the diagnosis code pointer in the SV107. Eliminated the ability to report this content two ways. This amount can be sent at the service line using a CPT/HCPCS code.
V. Conclusion The Subworkgroup will continue to evaluate the impact of these changes and will consider development of additional issue briefs in the future. VI. Acknowledgements Kelly Butler, Emdeon (WEDI representative) Gloria Davis, NextGen (WEDI representative) Rose Hodges, Aetna (ASC X12 representative) Jamie Mosteller, Cerner (ASC X12 representative) Nancy Spector, American Medical Association (WEDI representative) The co-chairs wish to express their sincerest thanks and appreciation to the members of the 837 Subworkgroup who participated in the creation of this document.