FAQs re: ICD-10

Congress voted to extend the October 1, 2014 ICD-10 implementation date for one year.  Covered entities should plan to complete the steps required to implement ICD-10-CM/PCS by no later than October 1, 2015.

ICD-10 codes must be used on all HIPAA transactions, including outpatient claims with dates of service, and inpatient claims with dates of discharge on and after October 1, 2015.

You can view the CMS requirements online at http://www.cms.gov/ICD10.
 

The Centers for Medicare and Medicaid Services (CMS) posted a final rule on August 24, 2012 that requires all HIPAA covered entities to adopt the ICD-10 code sets which replaces the ICD-9 code sets with a compliance date of October 1, 2015.

No.  The change to ICD-10 does not affect CPT coding for outpatient procedures and physician services.  ICD-10-PCS codes are for hospital inpatient procedures only.

The new ICD-10 code set provides a significant increase in the specificity of the reporting, allowing more information to be conveyed in a code.  The terminology has been modernized and has been made consistent throughout the code set.  There are also codes that are a combination of diagnoses and symptoms, so that fewer codes need to be reported to fully describe a condition.

Examples of the enhancements made with ICD-10 include:

 

• It enables reporting of laterality (right vs. left designations), reflecting the importance of which side of the body or limb (e.g., left arm, left kidney, left eye) is the subject of the evaluation.
• It restructures reporting of obstetric diagnoses. In ICD-9-CM, the patient is classified by diagnosis in relation to the episode of care. In ICD-10-CM, the patient is classified by diagnosis in relation to the patient’s trimester of pregnancy.

More information will be available as we progress toward the implementation of ICD-10 on October 1, 2015.

 

Date of service.  Claims for all health care services and hospital inpatient procedures performed on or after October 1, 2015, must use ICD-10 diagnosis and inpatient procedure codes.  Claims for services provided before October 1, 2015, must use ICD-9 diagnosis and inpatient procedure codes.

Yes.

All covered entities under the Health Insurance Portability and Accountability Act (HIPAA) of 1996 must implement the new code sets by October 2015. Covered entities required to use the new code sets include health plans, payers, providers, clearinghouses, health care information system vendors, billing agents and other services.

For HIPAA-covered entities, failure to transition to ICD-10 is not an option. Without ICD-10, providers will experience delayed payments or even non-payment and a possible increase in rejected, denied or pended claims. Payments to providers cannot be made without the proper ICD-10 coding.

For providers who have not yet started to transition to ICD-10, below are actions steps to take now:
• Develop an implementation plan, communicate the new system changes to your organization, and ensure that leadership and staff understand the extent of the effort the ICD-10 transition requires.
• Secure a budget that accounts for software upgrades/software license costs, hardware procurement, staff training costs, work flow changes during and after implementation, and contingency planning.
• Talk with your payers, billing and IT staff, and vendors to confirm their readiness status.
• Coordinate your ICD-10 transition plans among your partners and evaluate contracts with payers and vendors for policy revisions, testing timelines, and costs related to the ICD-10 transition.
• Create and maintain a timeline that identifies tasks to be completed and crucial milestones/relationships, task owners, needed resources, and estimated start and end dates.

It is recommended that you should begin your staff’s ICD-10 training immediately. The transition to ICD-10 is a major undertaking for providers, payers and vendors. Training needs will vary by organization type, size and staff role. For example, physician practice coders will primarily need to learn ICD-10-CM diagnosis coding, while hospital coders will need to learn both ICD-10-CM diagnosis and ICD-10-PCS inpatient procedure coding.

No. If the date of service on a claim is before October 1, 2015, and contains ICD-9 codes, then the claim will be accepted for payment. If the date of service is on or after October 1, 2015, and uses ICD-9 codes, then this claim will be rejected. All claims that contain a date of service on or after the federally mandated compliance date of October 1, 2015, MUST use ICD-10 codes to be accepted for payment.

Claims with service dates prior to October 1, 2015 will continue to be processed with the ICD-9 codes.
 

If an inpatient claim has a discharge and/or through date of service on or after October 1, 2015, then the entire claim must be billed using ICD-10 codes. If an outpatient claim spans the compliance date, then it is recommended that the provider(s) split the claim so that all applicable ICD-9 codes remain on one claim with dates of service (DOS) through September 30, 2015, and all ICD-10 codes be placed on a separate claim with DOS starting on or after October 1, 2015.

Yes, but only for dates of service prior to October 1, 2015. ICD-9 codes must be used for dates of service prior to October 1, 2015 only.

Claims for dates of service prior to October 1, 2015, must be submitted with ICD-9 codes, regardless of the date submitted.  Given the timeframes allowed for timely filing of claims and subsequent adjustments, this could be an extended period of time.

Yes, behavioral health providers submitting diagnositic assessments and authorization request to the LME-MCOs or to Value Options for ages 0-3 or Health Choice, at some point in the determined near future by DHHS, will need to convert, over to DSM-5. Some private insurance carriers have already begun making these transitions. The U.S. Department of Health and Human Services has mandated all health organizations begin using the ICD-10 code set no later than October 1, 2015. DHHS is working to determine the best start date for the implementation of DSM5, and prior to October 1, 2015 of ICD-10.

A DHHS workgroup consisting of staff from DMH/DD/SAS, DHB and DSOHF have been working together evaluating the changes that must be in place to ensure a smooth transition from DSM-IV-TR to DSM 5 for internal policy and practices. These changes would apply to clinicians who submit authorization request to provide services Medicaid recipients and / or State (DMHDDSAS) funded individuals. This workgroup has recently brought in additional members from the Council of Community Programs – Best Practice Standardization Committee members (consisting of LME-MCO, Provider and IT specialist representatives) to assist in this transition process and in determining a best start date for DSM-5 implementation. The goal of this work group has been to have implementation of DSM5 to happen months prior to the go live date of ICD-10. More information will be forth coming on this topic.

You are correct. Both claims and PAs will have to be split over the transition time. It will mean more work for both providers and payers, but it only happens over the October 1, 2015, implementation date and then going forward it will be easier.

A split claim is really two separate claims. You submit a claim with dates of service before October 1 and another claim for dates of service on and after October 1. Usually you would have sent one claim, but this one time, you will need to send two claims. And the same is true for PAs. Remember, by federal mandate NCTracks cannot accept ICD-9 codes for dates of service on or after October 1, 2015.

By this time, the providers who will be participating in ICD-10 testing with NCTracks have been selected and notified. We selected a limited number of providers representing a diversity of practices, specialties and facilities. These provider testers represent 80 percent of the claims submitted. We haven’t the bandwidth for every provider who offered to test. We hope to offer a limited testing tool for everyone this summer. In addition, there is an NCTracks ICD-10 Crosswalk at http://ncmmis.ncdhhs.gov/icdxwalk.asp. Note that new codes are being added regularly and some existing codes may change, so check back periodically. Between the crosswalk and this testing tool, we hope to make sure everyone is ready for ICD-10 in NCTracks.

From now until ICD-10 goes live in October, you can send your ICD-10 questions and comments to NCTracks-Questioner@dhhs.nc.gov. You will get an answer personally, and we will get an idea of the kinds of information you need. The best will be shared with everyone. We're all in this together.

The federal government has mandated that October 1 is the earliest we can accept a claim with ICD-10 codes.

The codes to use will be based on date of service, no matter when you submit the claim. So if the date of service occurred before October 1, but you’re submitting the claim after October 1, you will use ICD-9 codes.

Those codes are on the crosswalk, but as the directions state, you have to remove the decimal point. For example, enter ICD-9 code 707.10 as 70710. Once you do that, you will find the corresponding ICD-10 code.

You can find your codes on the NCTracks ICD-10 Crosswalk at http://ncmmis.ncdhhs.gov/icdxwalk.asp.  Remember to enter your ICD-9 codes without a decimal and the crosswalk should tell you the corresponding ICD-10 codes.

No, you will have to select the single correct ICD-10 code or codes that best describes the patient’s diagnosis. If that code isn’t apparent to you, ask the referring physician. Of course, as now, some claims have more than one diagnosis code.

99509 is a CPT code, not an ICD-9 code. CPT codes are NOT changing as part of this ICD-10 implementation, so you will continue to use 99509 after October 1. The crosswalk is only for ICD-9 codes.

You are correct. Most dental practices use ADA codes, not ICD codes. You can read about it here: https://nctracks.nc.gov/content/public/providers/ICD10/ICD10-announcements/Dental-Practices-and-ICD-10.html.

Yes, virtually. Using ICD-10 codes on NCTracks requires only a 30-minute webinar course. For more information, see the July 28 announcement.

We salute you for being on top of the issue. The primary concern is to ensure that all aspects of the claim submission process – from business forms to practice management software to trading partners/billing agents – are ready to use ICD-10 codes, and to know which codes you should use. For help with the latter, see the NCTracks ICD-10 Crosswalk at ncmmis.ncdhhs.gov/icdxwalk.asp.

Yes, that is correct.

Yes, that is correct.

Yes, that is correct.

Per DHB, yes.

Most claims are submitted as electronic X12 transactions to NCTracks, which are processed in near real time, as resources are available. In other words, the higher claim volume anticipated over the October 1 transition date will be queued up and processed as they are received. It may take somewhat longer to adjudicate the higher volume of claims. However, the NCTracks system is designed to accommodate fluctuations in claim volume. A normal checkwrite may vary from 2 million to as much as 7 million claims in a given week.

The ICD-10 codes are in the NCTracks system, but federal rules for ICD-10 implementation will not allow ICD-10 codes to be used prior to October 1. NCTracks is actively engaged in testing with providers and trading partners through July. After that we will take any lessons learned from testing and make any changes needed. The ICD-10 codes will be available for use in the NCTracks system on October 1.

Yes, clearinghouses are participating in testing. They include ClaimLogic, ClaimRemedi, CPSI, MedAssets, Emdeon, HealthFusion, HIS, PHYSICIAN'S COMPUTER COMPANY, Relay Health, SSI Group, and Trizetto Provider Solution.

The exception to split claims only applies to the hospital charges, not physician charges. During the transition from ICD-9 to ICD-10 over October 1, hospital claims will be based on date of discharge, while physician/professional claims will be based on date of service, which means they must be split.

No, the testing product didn’t work well for North Carolina. At this point, there aren’t plans for more testing beyond the provider/trading partner testing currently underway.

No, the residents don't need to see a physician to get their new codes. See what their ICD-9 codes correspond to in ICD-10 codes using the NCTracks ICD-10 Crosswalk at http://ncmmis.ncdhhs.gov/icdxwalk.asp.  You may find that there's a one-to-one match or that you can determine what the correct ICD-10 code would be for that resident. And if you can't, then you can call the physician's office and get their input.

You’re correct in most cases. Most dental practices don’t have to worry about ICD-10. For the exceptions, see this brief article: https://www.nctracks.nc.gov/content/public/providers/ICD10/ICD10-announcements/Dental-Practices-and-ICD-10.html.

Neither of those codes are ICD-9 diagnosis codes. S5125 is a HCPCS code and 99509 is a CPT code and these codes will not change. (That’s why they’re not in the NCTracks ICD-10 Crosswalk.) For a short article on how to tell the difference between codes, see this: https://www.nctracks.nc.gov/content/public/providers/ICD10/ICD10-announcements/How-to-Recognize-an-ICD-Code.html.

NC Medicaid does not have any requirements for mandatory ICD-10-CM external cause code reporting.

October 1, 2015

October 1, 2015

Only as necessary to accommodate ICD-10 codes. Otherwise, the RA will be the same.

There is no grace period for Medicaid. Only Medicare Part B claims are included. For more information, see the CMS Q&A.