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5010 Details


What is 5010?

  • 5010 is the newest version for ANSI X12 data. It will replace the 4010/4010A1 version.
  • The updated X12 Version 5010 of the HIPAA transaction standards represents substantial technical and operational improvements that respond to industry business needs and requests. With the transition to Version 5010 the industry will be better equipped to move toward an electronic health information environment via the increased and improved use of Electronic Data Interchange (EDI). The compliance date for Version 5010 is January 1, 2012.
  • The use of Version 5010 supports ICD-10-CM (Clinical Modification) for diagnosis and ICD-10-PCS (Procedure Coding System) for inpatient hospital procedure code sets that have been adopted in a separate regulation. The compliance date for ICD-10 conversion is October 13, 2013.

What transactions are affected?


The following transactions are included in the 5010 Final Rule:
  • 837 – Health Care Claims for professional, institutional and Dental
  • 835 – Health Care Remittance Advice
  • 270/271 – Health Plan Eligibility Inquiry and Response
  • 276/277 – Health Care Claim Status Request and Response
  • 278 – Health Care Services – Request for Review and Response
  • 820 – Health Plan Premium Payment
  • 834 – Health Plan Enrollment and Disenrollment
  • NCPDP D.0 – Retail Pharmacy Drug Claims
  • For a complete list follow this link to the HHS Final Rules and Regulations and go to Table 1

Who is affected by the change to 5010?

The legislation mandates industry-wide migration from the current 4010A1 version to a newly established 5010 version, for health information transactions governed under HIPAA. All HIPAA covered entities should begin planning for implementation of Version 5010. Entities such as:

  • Hospitals
  • Physicians
  • Dentists
  • Payers
  • Vendors
  • Billing Services
  • Laboratories
  • Clearinghouses

Clearinghouse and software vendors should start developing compliant products to ensure availability for the industry to test and implement. Vendors are critical in terms of providing the software and applications to make the transactions possible and to allow for early testing between trading partners.

The rule requires that internal testing be completed by December 31, 2010. This means that software and hardware changes in all systems must be in place as soon as possible in order to fully test each entity’s ability to send, receive and process standard transactions.

What are the major 5010 changes to consider?

  1. All providers MUST report NPI numbers for all providers'
    See “NPI Requirements” link in our website for specific details.
  2. Addresses for payers and providers will no longer allow P.O. Boxes
    Physical street addresses are the only acceptable form to report these.
  3. Patient Signature Source Code
    Even though this data element is currently required for all claims, the use of this data element has changed in HIPAA 5010 & is now only required when a signature was executed on the patient’s behalf.
  4. Number of DX Codes on a claim
    In preparation for the migration to ICD-10 diagnosis codes, the maximum number of DX codes was increased from 8 in 4010 to 12 in 5010. In addition, the Diagnosis Code is now required on all claims.
  5. Anesthesia Units/Minutes
    In 5010 Anesthesia services with procedure codes that do not have a specific time period defined in the description of the code must be reported using the value of MJ, which is minutes, reporting as units is no longer allowed.
  6. CTP Segment (NDC Drug Quantity) 2410 Loop
    In HIPAA 4010 the 2410 CTP segment for NDC Drug Quantity was Situational. In 5010, when submitting drug information, the NDC Drug Quantity is now required.
  7. Postal Codes
    The postal codes must be a 9 digit code for Billing & Service location addresses. Claimremedi will default 9998 in the last 4 bytes on the Billing Provider & Service Facility Location Addresses if only 5 digits are sent.

    *** These new requirements will be updated as more information becomes available. In the meantime, please refer to the implementation guides available for purchase @ http://www.wpc-edi.com or visit the CMS website for a side-by-side view of all 4010 to 5010 transactions @ http://www.cms.gov/ElectronicBillingEDITrans/18_5010D0.asp

Where can I find more information about the implementation of 5010?

For more information the Centers for Medicaid and Medicare Services (CMS) has provided Fact Sheets and Check Lists to assist in the transition to 5010. Please visit the CMS Educational Center at: http://www.cms.gov/Versions5010andD0/40_Educational_Resources.asp

Where can I purchase the 5010 X12 Implementation Guides

The implementation guides for Version 5010 are available for purchase at these two sites: X12.org @ http://store.x12.org/ or from WPC @ http://www.wpc-edi.com