Medical Billing and Coding: How to Prepare for the 5010 Platform - dummies

Medical Billing and Coding: How to Prepare for the 5010 Platform

With the move toward ICD-10 in medical billing, you will also be working with the 5010 platform. Some of the transition happens on the tech end of things, particularly with the transmission platforms your coding software uses to push claims through to the clearinghouse. In preparation for ICD-10, providers, clearinghouses, and payers have transitioned to 5010 transmission platforms, the method of transmitting claim files for payment to the insurance companies.

Using the 5010 platform, claims are transmitted electronically, and information that is entered into the billing software is then sent to the clearinghouse. In this system, each part of the claim can be pictured as a layer (or level), like this:

  • The first layer (or level) contains information about the patient.

  • The second layer contains information about the procedures and diagnosis codes.

  • The third layer contains payer-specific information: the payer name, payer ID number, patient ID number, group number, and so on.

  • The fourth layer contains the provider information, including name, address, and National Provider Identification (NPI) number.

  • The final layer is a view of the entire claim.

When a problem exists with the claim due to any of these transmission levels, the IT people fix it. All you can usually do as a coder is identify where in the claims process the problem may be. In other words, you’ll need to have your IT person on speed dial!

Even though this all sounds a little complicated, this move is good for several reasons. Proponents of ICD-10 argue that the improved data you get from using the new 5010 platform and subsequent coding changes will ultimately reduce healthcare costs and the ICD transition will pay for itself.

ICD-10 documentation will result in greater specificity in patient medical records, which will assist in assessment of treatment risk and frequency of procedural complications. It may also make documenting medical necessity for certain treatments easier.