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Medisoft ANSI 5010 and ICD-10 Information
Note: Only Medisoft V17 is ANSI 5010 Compliant.

Call us now at 888-691-8058 or 941-743-6666 for a free quote to upgrade to this GOVERNMENT REQUIRED new version of Medisoft.


All "Covered Entities" that are covered under the HIPAA mandates are required to update to the new ANSI 5010 standards by the January 1, 2012 deadline.

For electronic data interchange (EDI) charge transactions, HIPAA required the use of the ANSI (American National Standards Institute) format specifications and technical content.

Currently, EDI transactions are required to be submitted in ANSI version 4010 formats and the ICD-9 diagnosis code set. The new rule mandates that all covered entitites should begin migration and testing of EDI transactions in 2011 in order to be prepared for the Jan 1, 2012 deadline.

Who is required to use ANSI 5010? Answer: Insurance companies, health plans, health care clearinghouses, information trading partners, health information networks and health care providers who electronically transmit any HIPAA-standard transactions.

Why is this upgrade necessary? Answer: Part of the driving force in this new change is the adoption of the new ICD-10 diagnosis codes to be released. The new ANSI 5010 format is anticipated to become the EDI transaction format foundation for Healthcare now and in the future.

ANSI 5010

Can I continue submitting "print image" files to my own non-Medisoft approved clearinghouse?

We think not as the new format contains over 850 technical, structural and content changes to the healthcare data you will submit for electronic claims submission, as well as the ANSI data you can receive in response to other electronic EDI inquiries, such as eligibility and benefits, or claims status. If your clearinghouse makes tells you that you do not need to upgrade, please ask them to sign a acceptance of liability form and ask them to put in writing that they will reimburse you for any and all costs associated with "fixing claims" that are not ANSI 5010 compliant. NOTE: ANSI 5010 makes many more changes to the "Transaction line details", "Provider Details", along with many other areas of impact. Should you decide not to upgrade your software, you may be required to spend additional man hours trying to make each seperate claim ANSI 5010 compliant, which can tie up valuable billers time.

What are other benefits of transitioning to the new ANSI 5010 format?
Answer: Much of the ANSI v5010 changes are designed to improve consistency, standardization, clarity, efficiency and economy of electronic transactions in the entire USA health care network for both governmental and private carriers, providers, and payers. Other benefits include:

* Get faster, easier, more accurate eligibility information
* Reduce claim denials due to ineligibility
* Improve the process for obtaining prior authorization & referrals
* Reduce claim denials because of authorization or referral issues
* Make claim submission faster, more efficient and with less errors
* Eliminate the use of local codes
* Use the same set of codes with all health plans
* Get electronic remittance advices from health plans
* "Auto-post" payments to your system - quickly and accurately
* Electronically request claim status information
* Reduce the costs of your claims processing and free up valuable staff resources, while protecting the security and privacy of health care information.

When should I upgrade and start using ANSI 5010? Answer: As soon as possible as you do not want to negatively effect your cash flow when the clearinghouses and insurance carriers start enforcing the new guidelines Jan 1 , 2012.

What are the penalties for non-compliance? The first and foremost penalty is the loss 00of cash flow to your medical practice. Imagine if your office processes just $50,000 of claims per month. A 10% rejection rate could result in $5,000 PER MONTH of denied claims, and additionally, lost time and wages for your staff to fix the problems along with added headaches and anxiety of the additional stress this would involve.

The law does provide for fines for non-compliance. The Secretary of HHS may impose a civil monetary penalty on any person or covered entity who violates any HIPAA requirement. The civil monetary penalty for violating transaction standards is up to $100 per person per violation and up to $25,000 per person per violation of a single standard per calendar year.

What are "Covered Transactions"? Answer:Transactions are activities involving the transfer of health care information for specific purposes. Under HIPAA Administration Simplification if a health care provider engages in one of the identified transactions, they must comply with the standard for that transaction. HIPAA requires every provider who does business electronically to use the same health care transactions, code sets, and identifiers. HIPAA has identified ten standard transactions for Electronic Data Interchange (EDI) for the transmission of health care data. Claims and encounter information, payment and remittance advice, and claims status and inquiry are several of the standard transactions.

Code sets are the codes used to identify specific diagnosis and clinical procedures on claims and encounter forms. The CPT-4 and ICD-9 codes that you are familiar with are examples of code sets for procedure and diagnosis coding. Other code sets adopted under the Administrative Simplification provisions of HIPAA include codes sets used for claims involving medical supplies, dental services, and drugs. As mentioned above, the new ANSI 5010 format will allow for the changes in ICD-10 codes that will be required by 2013. Additional changes in Medisoft are anticipated that will allow Medisoft to use ICD-10 codes in future versions.


How do I upgrade my Medisoft software to be compliant with Medisoft ANSI 5010? Answer: If you are on any other version of Medisoft besides Medisoft Version 17, you need to upgrade. Call us at 888-691-8058 or 941-743-6666 for your free quote to upgrade now.

Here is a snapshot of what the changes look like in the Medisoft Version 17


Medisoft HIPAA X12 Version 5010


These changes include new windows/tabs, restructured windows or moved fields, menu changes, new fields, additional options, and other changes.


New Windows or Tabs


There are three new windows or tabs.


Edit Claim window, new EDI Note tab.(for Claim level notes)


The EDI Note tab has been added to the Edit Claim window. Information on this tab is pulled from the Case Window, Comment tab. This tab allows you to change various note information at the claim level so it does not affect the data in the case record itself.




EDI Notes and List windows (for Transaction Line Item notes)


A new EDI Notes window will allow you to enter notes of various types for electronic transmission. The corresponding List window will open when the new EDI Notes button is clicked during Transaction Entry, Patient or Guarantor Ledger, or Unprocessed Transactions.




From this window, you can create or edit EDI Notes using the EDI Note window.




You can use this window to enter four different types of notes. Depending on your selection in the Note Type field, the fields will change.


On the Transaction Entry and Patient Ledger windows, you can see if there is an EDI note associated with a particular line item by adding the EDI Notes column, using the Grid Columns window


Note: This column will NOT display by default. When you add it, the Caption will be EDINotes and the Width will be 4; however, after clicking it, the Caption will simply be E with a width of 2. If you attempt to change it back to EDINotes, it will return to E automatically.


Warning: You must close any open EDI Notes windows before you can return to Transaction Entry, Unprocessed Transactions, or the Ledger windows.


Restructured windows and moved fields


Several fields have been moved and windows have been restructured and rearranged to accommodate the moved fields.


  • Allergies and Notes, as well as EDI notes, have been moved to the Comments tab of the Case window.



  • Condition Codes have been moved from the UB04 window, FL 4 to 41 tab to the Condition tab of the Case window to accommodate changes that allow condition codes to be used in professional claims.


NOTE: Condition Codes will not be copied if the user uses Copy Case.




New Fields added


Several new fields have been added throughout the program. Below is a table describing the window where the new field is located, the field name, and its purpose.


Window where the field is located

Field Name


Practice Information, Practice Tab


Enter the general email address for the practice.

Case Window, Case Policy 2 Tab

Medicare Secondary Reason

Allows you to specify the reason why Medicare coverage is secondary. Visible only if an insurance with the Type of Medicare is selected.

Patient/Guarantor, Name, Address Tab

Date of Death

Enter the date on which the patient died, if necessary.

Patient/Guarantor, Name, Address Tab


Allows you to enter a suffix for the patient's name, such as Jr.

Windows that show the patient's name will now display the suffix as well.

Patient/Guarantor, Name, Address Tab


Select the patient's race.

Patient/Guarantor, Name, Address Tab


Select the patient's ethnicity.

Case Window, Medicare and Tricare Tab

Special Program Code

Allows you to select any special program from the drop-down list.

Provider Window, Address Tab

Middle Name

Allows you to enter the middle name of the provider.

Referring Provider Window, Address Tab

Middle Name

Allows you to enter the middle name of the referring provider.

Case Window, Policy 1, 2, and 3 Tabs

Group Name

Enter the group name for the insurance plan.

Procedure/Payment/Adjustment Window, General Tab

Purchase Service Amount

Use this field to enter amounts you pay a lab or other vendor for technical services they performed for you for the procedure, such as lab testing. This amount will appear on the Transaction Entry window and a summary total of these amounts on the Claim window.

Procedure/Payment/Adjustment Window, General Tab

NDC Unit Price

Use this field to enter the unit price of a drug or biologic.

Transaction Details

Reference ID Qualifier

Use this field to specify a qualifer for the Rx#/Reference ID.

Procedure/Payment/Adjustment Window, General Tab

NDC Unit of Measurement

Use this field to enter the unit of measurement that is used for the drug or biologic.


Menu Changes


The option for UB-04 Condition Codes has moved from the UB04 Code Lists menu to the main Lists menu.


Additional Options


  • Additional Diagnosis Codes: The program now allows you to have up to 12 diagnosis codes for a case. The following fields and windows are affected.

  • Program Options, Data Entry tab: Number of Diagnosis can now be set from 4-12.

  • Transaction Entry:You can now have columns for up to 12 diagnosis codes, as well as up to 12 column check boxes to specify if the code is being used for that procedure.

  • Unprocessed Transactions: You can now have up to 12 columns for diagnosis codes on the List window, as well as the Edit window.

  • Case Window, Diagnosis Tab: You can now have up to 12 Default Diagnosis fields

  • Patient/Guarantor, Name, Address Tab, Sex field: Added the option Unknown

  • Case Policy 1, 2, and 3 tabs: Relationship to Insured has several new options.


Other Changes

  • Medicaid Referral Access # field is now called Referral Access #.

  • Case Window, Condition Tab: First Consultation Date field is now called Initial Treatment Date.

  • Case Window, EDI Tab: Timely Filing Indicator field is now a drop-down instead of a free-form text field.

  • Case Window, EDI Tab: The EPSDT Referral Code field is now a drop-down.

  • Insurance Type Code: Removed this field from the EDI tab on the Case window.

  • Claim Filing Indicator Code: Added four new items to the drop-down:

  • Dental Maintenance Organization

  • Federal Employees Program

  • Other Federal Program

  • Commercial Insurance Co

  • Relationship to Insured: items in the list have been rearranged so that values valid for 5010 are on top and legacy values for 4010 are on the bottom.

  • Timely Filing Indicator: This is now a drop-down with preset values, to ensure that a valid value is always selected.


How do I upgrade my Medisoft software to be compliant with ANSI 5010? Answer: If you are on any other version of Medisoft besides Medisoft Version 17, you need to upgrade. Call us at 888-691-8058 or 941-743-6666 for your free quote to upgrade now.  Do you need Medisoft Support to understand how to setup your system for ANSI 5010?  Then call our Medisoft Support Number at 888-691-8058.

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