International Classification of Diseases (ICD)-10: Are You Ready? Note! Contents are subject to change and are not a guarantee of payment.

Transcription

1 International Classification of Diseases (ICD)-10: Are You Ready? Note! Contents are subject to change and are not a guarantee of payment.

2 Objectives Provider community ICD-10 compliance What you can expect from us Frequently asked questions Available provider resources 2

3 A Note to Dental Providers! ICD-10 will not affect dental providers unless you are billing for medical services using a CMS 1500 form. An example of a dental service that we may cover under medical is the extraction of an impacted tooth. Dental providers are exempt from billing with diagnosis codes in general. If a dental provider chooses to bill with a diagnosis code, you must use ICD-10 coding for dates of service (DOS) on or after 10/1/

4 We Are Ready for ICD-10 We recognize that the federally mandated implementation of ICD-10 code sets will lead to a substantial change in the health care industry. We will begin accepting and processing ICD-10 diagnosis and procedure codes on October 1,

5 About ICD-10 Codes ICD-10, Clinical Modification/Procedure Coding System (ICD-10 CM/PCS) On October 1, 2015, the United States will transition from the 9 th edition, ICD-9, to the 10 th edition, ICD-10, as the medical code set for medical diagnoses and inpatient hospital procedures. 5

6 About ICD-10 Codes ICD-10 consists of two parts: 1. ICD-10-CM (diagnosis coding) developed by the Centers for Disease Control and Prevention for use in all U.S. health care settings. 2. ICD-10-PCS (inpatient procedure coding) developed by the Centers for Medicare and Medicaid Services (CMS) for use in U.S. inpatient hospital settings only. 6

7 About ICD-10 Codes ICD-10-CM codes have been expanded to include three-seven digits. (ICD-9-CM codes only use three-five digits.) ICD-10-PCS use seven alphanumeric digits. The change to ICD-10 CM/PCS does not affect current procedural terminology (CPT) coding for outpatient procedures and physician services. The transition is required for everyone covered by the Health Insurance Portability and Accountability Act (HIPAA). ctices pdf 7

8 Why and When? The use of ICD-10 should: Advance public health research and emergency response through detection of disease outbreaks and adverse drug events Support innovative payment models that drive quality of care The new codes will allow for more specific details on a patient s condition. The effective date for the transition to ICD-10 codes was October 1,

9 Differences Between ICD-9 and ICD-10 ICD-9 Diagnosis Codes No laterality Three-five digits First digit is alpha (E or V) or numeric Digits two-five are numeric Decimal is placed after the third character No placeholder characters ICD-10 Diagnosis Codes Laterality Right or left account for > 40% of codes Seven digits Digit one is alpha; digit two is numeric Digits three-seven are alpha or numeric Decimal is placed after the third character X placeholders 14,000 codes 69,000 codes to better capture specificity Limited severity parameters Limited combination codes One type of Excludes Notes Extensive severity parameters Extensive combination codes to better capture complexity Two types of Excludes Notes 9

10 Differences Between ICD-9 and ICD-10 Other Important Changes to Note in ICD-10-CM Importance of Anatomy: Injuries are grouped by anatomical site rather than by type of injury Incorporation of E and V Codes: The codes corresponding to ICD-9-CM V codes (Factors Influencing Health Status and Contact with Health Services) and E codes (External Causes of Injury and Poisoning) are incorporated into the main classification rather than separated into supplementary classifications as they were in ICD-9-CM 1 0

11 Differences Between ICD-9 and ICD-10 New Definitions: In some instances, new code definitions are provided reflecting modern medical practice (e.g., definition of acute myocardial infarction is now four weeks rather than eight weeks) 11

12 Differences Between ICD-9 and ICD-10 Restructuring and Reorganization: Category restructuring and code reorganization have occurred in a number of ICD-10-CM chapters, resulting in the classification of certain diseases and disorders that are different from ICD-9-CM Reclassification: Certain diseases have been reclassified to different chapters or sections in order to reflect current medical knowledge 12

13 What Does All This Mean? Before the Compliance Date Open fracture of shaft of femur After the Compliance Date S72.351C Displaced comminuted fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB or IIIC 13

14 What Does All This Mean? Common Conditions Coded from ICD-9 to ICD-10: Family Practice 14

15 What Does All This Mean? Remember to bill all codes for each patient to avoid requests for medical records or Healthcare Effectiveness Data & Information Set (HEDIS ) requests later. 15

16 Are You Ready? Identify current ICD-9 systems and work processes Talk with system vendors about ICD- 10 accommodations Discuss implementation with clearinghouses and billing services Talk with payers about ICD-10 implementation and contract agreements Identify potential changes to workflow and business processes Assess staff training needs Budget for time and costs related to ICD- 10 implementation Conduct ICD-10 test transactions with payers and clearinghouses ICD-10 Ready! 16

17 What Happens on October 1, 2015? We will accept ICD-10 codes on all claims with DOS 10/1/2015 and later. Claims and authorization data will be DOS-driven! 17

18 Clearinghouse Readiness All clearinghouses that transmit claims to us are ICD-10 ready, and many have been ready for over two years. Some clearinghouses will not transmit claims for DOS on or after 10/1/2015, that you submit with ICD-9 codes. If your practice is ICD-10 ready, then your claims should be transmitted and processed successfully. For providers without a clearinghouse, My Insurance Manager SM is available to submit claims at 18

19 Professional Claims You should code all DOS prior to October 1, 2015, using ICD-9 codes. If you file for services that span October 1, 2015, you must split the claim. All services rendered before 10/1/2015 file with ICD-9 codes on one claim All services rendered on or after 10/1/2015 file with ICD-10 codes on one claim With the exception of dental providers, no other medical practitioner, institutional or professional, is exempt from coding with ICD-10 for DOS on or after 10/1/2015! 19

20 Inpatient Claims Admission and discharge dates before 10/1/2015 Admission date before 10/1/2015 and discharge date after 10/1/2015 Admission and discharge date on or after 10/1/2015 You should file claims with ICD-9 codes You should file claims with ICD-10 codes You should file claims with ICD-10 codes 20

21 Facility Outpatient Claims Statement From and Through dates before 10/1/2015 You should file claims with ICD-9 codes Statement From date before 10/1/2015 and Statement Through date after 10/1/2015 One claim filed with ICD-9 codes for services rendered before 10/1/15 Another separate claim filed with ICD-10 codes for services rendered after 10/1/15 Statement From and Through dates on or after 10/1/2015 You should file claims with ICD-10 codes 21

22 Authorizations As mandated by Department of Health and Human Services (DHHS), you should use ICD- 10 codes when you request precertifications for DOS on or after 10/1/2015. We will only accept requests for authorizations with ICD-10 codes effective 10/1/

23 Authorizations An authorization with an ICD-9 code for care with a beginning DOS before 10/1/2015 will not need an update if the end DOS goes beyond 10/1/2015. The existing authorization will remain valid. If you get an authorization prior to 9/30/2015, and there is a level of care change after 10/1/2015, you will need to get a new authorization for the new level of care. 23

24 Testing BlueCross BlueShield of South Carolina and BlueChoice HealthPlan began ICD-10 testing with our South Carolina providers in April Professional Claims Testing As of 9/1/2015, we have tested 1750 claims from 95 providers for ICD-10 readiness. In addition, BlueCross and BlueChoice tested nearly half a million claims internally. 24

25 Testing For more information about ICD-10 testing with BlueCross and BlueChoice, please 25

26 Questions & Answers Participants submitted questions prior to the presentation. Here are some of the frequently asked questions (FAQs) and their answers. Look to our websites and for additional ICD-10 FAQs. 26

27 Questions & Answers Your Question What should I do if our claims are continually rejected or denied for ICD-10 coding? Our Answer You can use My Insurance Manager to submit ICD-10-compliant claims to our plans or resubmit a corrected claim through your clearinghouse. What is an ICD-10 qualifier, and how will it be used? If we submit the wrong ICD-10 code, will we get a grace period to put in the right one? In the electronic submission, a qualifier is a data element that tells you what is coming in the next data element. It will tell the system which code set (ICD-9/ICD-10) to validate against. Your practice management system will generate this for you. The qualifier field on the CMS 1500 paper form is box 21. You can submit a corrected claim just as you do today. 27

28 Questions & Answers Your Question Our Answer Will you base the necessary codes for claims on the date submitted or the DOS? Will our claims reject if we submit RT/LT modifiers? Do we need to update diagnosis codes for existing authorizations for ongoing services? You should submit claims with the appropriate ICD-10 codes based on the date of service. For example, if the DOS is 9/3/2015, and you will submit it 10/5/2015, you would submit with ICD-9 codes because the DOS is prior to the 10/1/2015 mandate. We still require modifiers (including RT/LT) on procedure codes even if the diagnosis code specifies laterality. We did not change procedure code requirements. No. If you get an authorization with an ICD-9-CM code for care with a begin DOS before 10/1/2015, you will not need an update if the end DOS goes beyond 10/1/2015. The existing authorization will remain valid. 28

29 Questions & Answers Your Question Our Answer Should all claims for dates of service prior to 10/1/2015 use ICD-9-CM codes if we submit the claim as late as October or November? If I have a previous authorization with an ICD-9- CM code for a DOS before 10/1/2015, but then change the patient s visit to a date after 10/1/2015, am I required to get a new authorization? We determine ICD-10-CM claims filing by the date of service. If the date of service is prior to 10/1/2015, but you filed the claim after the ICD-10- CM implementation date, you should submit the claim with ICD-9-CM codes. Yes. If you change the DOS to a later date after ICD-10-CM implementation, you will need to get a new authorization. 29

30 Questions & Answers Your Question Our Answer Is there going to be a new CMS 1500 form? If we have a pregnant patient who comes into the office, and we get an authorization for her pregnancy before 10/1/2015, does this mean we have to get a new pregnancy authorization after 10/1/2015? According to the CMS, it will accept only the revised CMS-1500 form as of April 1, CMS has not indicated a revision to the current form. You can visit for additional information. No, you will not have to update the authorization. 30

31 Questions & Answers Your Question Our Answer For durable medical equipment (DME) rentals, will I need to get a new authorization for service that spans 10/1/2015? For services starting before 10/1/2015, complete the authorization using the ICD-9-CM code. We will require no updates even though you will provide some of the services after 10/1/2015. For services that begin 10/1/2015, you should get authorization using ICD-10-CM codes. Where do we find the new ICD-10-CM DX codes? There are many places on the Web where you can find ICD-10-CM code information. Washington Publishing Company ( provides hardcopy manuals for a cost. You can also visit a free medical coding website for current and accurate ICD-10-CM/PCS codes. These sites are not managed by BlueCross BlueShield of South Carolina and BlueChoice HealthPlan. The sites are solely responsible for the information provided. 31

32 Questions & Answers Your Question Our Answer Will diagnosis and procedure codes change or remain the same? Do you process claims by DOS or date of claim submission? If we authorize for a DOS prior to 9/30/2015, but the DOS changes to a new date after 10/1/2015, do you require a new authorization? ICD-10-CM codes will change. There are no plans at this point to address procedure (CPT) coding. The mandate is specific to ICD-9-CM diagnosis and procedure codes converting to ICD-10-CM. CPT coding is a completely different code set and is not addressed in this mandate. We process claims by DOS. Yes. If you change the DOS to a later date after ICD-10-CM implementation, you will need to get a new authorization. 32

33 Questions & Answers Your Question Our Answer If we submit a claim with ICD- 9-CM and ICD-10-CM codes, is the authorization going to be valid? Yes, the authorization will be valid. Remember that you will need to file ICD-9-CM codes on a separate claim from the ICD-10-CM codes. Should we normally request the diagnosis code along with the CPT code for authorization? Is a level of care and plan of care the same thing? I work for a physical, occupational and speech therapist who uses plan of care. You should always request the diagnosis code when getting an authorization. They are different. The level of care applies to inpatient claims for a skilled nursing facility. The plan of care refers to the treatment plan. 33

34 Questions & Answers Your Question Our Answer Does the ICD-10-CM affect dental codes at all? Will BlueCross require external mechanism codes on a claim when we submit ICD- 10-CM codes for fractures, sprains or strains? This change impacts all dental claims you file through the patient s medical benefit. An example of a dental/oral surgical procedure that we may cover under medical is the extraction of an impacted tooth. The codes corresponding to ICD-9-CM V codes (Factors Influencing Health Status and Contact with Health Services) and E codes (External Causes of Injury and Poisoning) are incorporated into the main classification rather than separated into supplementary classifications as they were in ICD-9-CM. Will we be able to appeal claims filed with ICD-9-CM codes with DOS after 10/1/2015? If you receive a denial on a claim because you filed an ICD-9-CM code instead of the ICD-10-CM code, you can file a corrected claim with the ICD- 10-CM code to have us reconsider the claim for payment. 34

35 Questions & Answers Your Question Our Answer What happens if we only submit the ICD-10-CM code for fractures, strains or sprains? You have to report the appropriate ICD-10-CM code that includes the reference to the external cause of injury when you submit the claim. For example, the ICD-9-CM code is closed fracture of other bone of wrist. This same condition is converted to ICD-10-CM as S62.153A, displaced fracture of hook process of hamate [cuneiform] bone, unspecified wrist, initial encounter for closed fracture. Will BlueCross follow Medicare s one year allowance to accept all claims as long as the code is in the code family? No. We are expecting providers to file with the appropriate coding. CMS is only providing a grace period on penalties associated with incorrect filing. CMS also expects correct coding. 35

36 Questions & Answers Your Question Our Answer Is the decimal required when submitting codes? Yes, we require the decimal when you submit claims through the Web. The decimal is omitted from ICD-9 and ICD-10-CM in the electronic claim and the paper UB-04. It is optional on the CMS and the ADA-JD430. Do you require us to file all ICD-10-CM codes with seven alphanumeric characters? Certain ICD-10-CM categories have applicable seventh characters. We require the applicable seventh character for all codes within the category, or as the notes in the Tabular List instruct. The seventh character must always be the seventh character in the data field. If a code that requires a seventh character is not six characters, you must use a placeholder X to fill in the empty characters. You can find additional ICD-10-CM coding guidelines at nloads/icd10cm-guidelines-2015.pdf. 36

37 Questions & Answers Your Question Our Answer How will you communicate to providers any issues with ICD-10-CM implementation? If something goes wrong, will BlueCross send information and updates, or will providers have to go to your website? Are we allowed to submit ICD- 9 and ICD-10-CM codes together on a claim? We will add bulletins to and Our Provider Services call center will also include any ICD-10-CM announcements via the voice response unit (VRU). No, you cannot file a claim with both ICD-9 and ICD-10-CM codes. You will need to file with ICD-9 codes on one claim, and file with ICD-10-CM codes on a separate claim. What does the F in front of the ICD-10-CM code signify? Each alphanumeric digit corresponds to a category (family) of codes in the ICD-10-CM manual. The F is assigned for mental and behavioral health disorders. 37

38 Questions & Answers Your Question Our Answer Please explain the qualifier in block 21. Do we enter that on the hardcopy claim? Our preferred method is for you to submit claims to us electronically. We have a website available for you to key claims if you do not have systems programmed to electronically submit to us. If you are filing your claims hardcopy, you should indicate ICD-10-CM coding with a 0 in block 21. Are any medical policies going to change? We review and update medical policies annually, but we updated these policies to include the appropriate ICD-10-CM codes that are applicable to each policy. Why is My Insurance Manager showing a highlighted section in the template for submitting claims? After 10/1/2015, My Insurance Manager will allow you to submit ICD-10-CM codes. We prepared the system early and have highlighted the section to prevent you from filing claims with ICD-10-CM codes prior to the compliance date. 38

39 Questions & Answers Your Question Our Answer I am curious how ICD-10-CM will affect mental health professionals who are not Medicare or Medicaid providers. Will it change our CPT codes or will you use it in place of DSM-5 diagnosis codes? Will there be a grace period to update the level of care on an authorization? Do you require medical records for authorizations if we don t know the specific diagnosis code? DSM-5 contains both ICD-9-CM and ICD-10-CM codes. You should update the level of care on an authorization as soon as possible. It depends on the service that is requested. Many times we can accept a general diagnosis code to complete an authorization. For those services that require a specific diagnosis code to authorize, we will require medical records. 39

40 Questions & Answers Your Question Our Answer In a physical therapy office, do we add A, D or S to the end of the codes? Most categories have seventh character extensions that are required for each applicable code, and most categories have three extensions (with the exception of fractures): A = Initial encounter (patient receiving active treatment for injury, such as surgical treatment, emergency department encounter and evaluation/treatment by new physician) D = Subsequent encounter (patient received active treatment of the injury and receiving routine care for injury during the healing or recovery phase, such as cast change/removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow-up visits following injury treatment) S = Sequela (used for complications or conditions that arise as a direct result of an injury, such as scar formation after a burn) 40

41 Questions & Answers Your Question Our Answer We are a hearing aid clinic that bills only for hearing aids. The only codes we have used are the diagnosis codes and The CPT codes we use most frequently are V5257 and V5261 (BTE's monaural and binaural, respectively). Are these changing? If so, can you provide the corresponding codes we need to use? You may find the website beneficial to you to help convert your ICD-9-CM codes to ICD-10-CM codes. For the examples you ve provided, the comparable ICD-10-CM code is H90.41 or H90.42 for ICD-9-CM code ; and ICD-10-CM H90.3 for ICD-9-CM ICD-10-CM codes will change. There are no plans at this point to address current procedural terminology (CPT) coding. The mandate is specific to ICD-9-CM diagnosis and procedure codes converting to ICD-10-CM. CPT coding is a completely different code set and is not addressed in this mandate. 41

42 Resources s/icd-10mythsandfacts.pdf s/icd10introduction pdf -Questions-and-Answers-Related-to-the-July CMS-AMA-Joint-Announcement.pdf 42

43 Additional Information Name Area Telephone Contessa Struckman Provider Education Shamia Gadsden Provider Education Ashlie Graves Provider Education Jada Addison Provider Education Mary Ann Shipley Provider Education Sandy Sullivan Provider Education Sharman Williams Provider Education Bunny Thomas Provider Education Elizabeth Duvall Provider Education Provider advocates are always eager to assist you!

44 Resources Name Area Telephone Teosha Harrison Manager, Provider Relations & Education Bart Strickland Director, EDI Services N/A Kim Lewis Manager, EDI Services N/A Mark Harder Business Analyst, EDI Services N/A ICD-10 Testing N/A These individuals are essential to the service we give to our providers. 44