WEDI Strategic National Implementation Process (WEDI SNIP) ICD-10 Workgroup. ICD-10 Issue Brief. ICD-10 Impact to HIPAA Transactions June 7, 2013

Transcription

1 WEDI Strategic National Implementation Process (WEDI SNIP) ICD-10 Workgroup ICD-10 Issue Brief ICD-10 June 7, 2013 Workgroup for Electronic Data Interchange 1984 Isaac Newton Square, Suite 304, Reston, VA T: //F: Workgroup for Electronic Data Interchange, All Rights Reserved Accredited Standards Committee (ASC) X12, Incorporated 241 East Fourth Street, Unit 202, Frederick, MD T: x ASC X12 Inc., All Rights Reserved

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3 CONTENT I. Introduction... 5 II. Purpose of this Issue Brief... 5 III. What Transactions are impacted by ICD-10?... 6 A. Transactions Impacted... 6 B. Transactions Not Impacted... 6 IV. Acknowledgements... 6 APPENDIX... 7 Data Elements within Transactions Impacted by ICD A. Health Care Services Review Request (278 X217)* 7 B. Health Care Services Review Response (278 X217)*... 8 C. Benefit and Enrollment (834 X220A1)*... 9 D. Professional Claim (837 X222A1)*... 9 E. Institutional Claim (837 X223A2)* F. Dental Claim (837 x224a2)* G. Health Care Eligibility Benefit Inquiry (270 X279A1)* H. Health Care Eligibility Benefit Response (271 X279A1)*... 12

4 Disclaimer This document is Copyright 2013 by The Workgroup for Electronic Data interchange (WEDI) and the Accredited Standards Committee (ASC) X12 Incorporated. It may be freely redistributed in its entirety provided that this copyright notice is not removed. It may not be sold for profit or used in commercial documents without the written permission of the copyright holder. This document is provided as is without any express or implied warranty. Note that the copyright on the underlying ASC X12 Standards is held by DISA on behalf of ASC X12. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. If you require legal advice, you should consult with an attorney. The information provided here is for reference use only and does not constitute the rendering of legal, financial, or other professional advice or recommendations by the Workgroup for Electronic Data Interchange or ASC X12 Inc.. The listing of an organization does not imply any sort of endorsement and the Workgroup for Electronic Data Interchange and ASC X12 Inc. takes no responsibility for the products, tools, and Internet sites listed. The existence of a link or organizational reference in any of the following materials should not be assumed as an endorsement by the Workgroup for Electronic Data Interchange (WEDI), ASC X12 Inc., or any of the individual workgroups or sub-workgroups of the WEDI Strategic National Implementation Process (WEDI SNIP). Document is for Education and Awareness Use Only

5 ICD-10 I. Introduction The implementation of ICD-10 is a project unlike any that the health care industry has attempted in the last 20 years. This project impacts virtually every business process and system in health plans, provider facilities, clearinghouses, and vendors. The breadth and depth of this project means that the risks for the entire value chain are enormous. As part of the testing process for ICD-10, it is imperative that we have a clear understanding of where the ICD-10-CM and ICD-10-PCS codes are used in the transactions required under HIPAA and used in the health care industry to exchange diagnosis and procedure information. This issue brief is a joint effort between WEDI and ASC X12 Inc.and is designed to help the industry better understand where to focus the transaction testing and to ensure that appropriate changes are implemented prior to beginning the testing and implementation of the new code sets. II. Purpose of this Issue Brief The purpose of the Issue Brief is to provide information on the transactions that are impacted by ICD-10 as well as the placement of the codes within the transactions. Knowing where all of the touch points are will help facilitate implementation and testing of ICD-10-CM and ICD-10-PCS. Although it can be argued that implementation of version 5010 of the ASC X12 transactions tested the format that will be used to carry ICD-10 codes, the industry did not focus on assuring the codes were correctly assigned and reflected on transactions or that transactions carrying ICD-10 codes were correctly processed in front end or downstream applications. This document will help highlight the transactions and content that will need to be validated as part of the ICD-10 testing effort. Testing might include verification that transaction and code formats are correct, codes are valid, number of occurrences is appropriate, etc. This document can also be used as input to an ICD-10 impact assessment and subsequent remediation planning.

6 ICD-10 III. What Transactions are impacted by ICD-10? Note: Detailed data element information by transaction is described in the Appendix. A. Transactions Impacted The following list of transactions represents those adopted (ASC X12N Version 5010) under the HIPAA Transactions and Code Sets Final Rule that will be impacted by the change to ICD-10. Transactions Impacted Health Care Claim: Professional (837) Health Care Claim: Institutional (837) Health Care Claim: Dental (837) Health Care Services Review Request for Review and Response (278) Health Care Eligibility Benefit Inquiry and Response (270/271) Benefit Enrollment and Maintenance (834) X222A1 X221A2 X224A2 X217 X279 X220A1 B. Transactions Not Impacted The following list of transactions represents those adopted under the HIPAA Transactions and Code Sets Final Rule that will not be impacted by the change to ICD-10. Please note that although the Health Care Claim Payment/ Advice (835) is not directly impacted in terms of carrying an ICD-10 code, the information on this transaction is indirectly impacted by ICD-10 by virtue of potential variations in dollar amounts or via CARC and RARC codes. Transactions Not Impacted Health Care Claim Payment/ Advice (835) Health Care Claim Status Request and Response (276/277) Payroll Deducted and Other Group Premium Payment for Insurance Products (820) X221A1 X212 X218 IV. Acknowledgements a. Debbi Meisner b. Margaret Weiker c. Kelly Butler d. Deb McCachern e. Jim Daley The ICD-10 co-chairs wish to express their sincerest thanks and appreciation to the members of ASC X12 and WEDI who participated in the creation and review of this document.

7 ICD-10 APPENDIX Data Elements within Transactions Impacted by ICD-10 The following tables represent the data elements impacted by ICD-10 for each transaction adopted under the HIPAA Transactions and Code Sets Final Rule. Note that for version 5010 a generic qualifier is being used in many instances. However, when a future version of these transactions is adopted, the generic qualifier (and/or code) will be replaced by a new value. A. Health Care Services Review Request (278 X217)* Patient Diagnosis 2000E HI01-1 through HI12-1 ABF ICD-10-CM Diagnosis ABJ ICD-10-CM Admitting Diagnosis ABK ICD-10 Principal Diagnosis* APR ICD-10 Patient s Reason for Visit *available for HI01 only. Patient Diagnosis Code 2000E HI01-2 through HI12-2 Surgical Procedure 2000E CR610 No ICD-10-PCS available in Surgical Procedure Code 2000E CR611 No ICD-10-PCS available in Procedure Code 2000E SV202-1 ZZ ICD-10-PCS Procedure Code 2000E SV202-2 Procedure Code 2000E SV202-8 * ASC X12/005010X Health Care Services Review Request and Response

8 ICD-10 B. Health Care Services Review Response (278 X217)* Patient Diagnosis 2000E HI01-1 through HI12-1 Patient Diagnosis ABF ICD-10-CM Diagnosis ABJ ICD-10-CM Admitting Diagnosis ABK ICD-10 Principal Diagnosis* APR ICD-10 Patient s Reason for Visit *available for HI01 only. Patient Diagnosis Code 2000E HI01-1 through HI12-1 Patient Diagnosis Code Surgical Procedure 2000E CR610 Medical Code No ICD-10-PCS available in Surgical Procedure Code 2000E CR611 Medical Code No ICD-10-PCS available in Procedure Code 2000E SV202-1 ZZ ICD-10-PCS Procedure Code 2000E SV202-2 Procedure Code 2000E SV202-8 * ASC X12/005010X Health Care Services Review Request and Response

9 ICD-10 C. Benefit and Enrollment (834 X220A1)* Diagnosis Code 2200 DSB07 ZZ ICD-10-CM Diagnosis Code 2200 DSB08 * ASC X12/005010X2220A1 834 Benefit and Enrollment D. Professional Claim (837 X222A1)* Diagnosis Code 2300 HI01-1 through HI12-1 Diagnosis Code ABK ICD-10-CM Principal Diagnosis ABF ICD-10-CM Diagnosis Diagnosis Code 2300 HI01-2 through HI12-2 Diagnosis Code * ASC X12/005010X222A1 837 Professional Claim

10 E. Institutional Claim (837 X223A2)* ICD-10 Principal Diagnosis Code 2300 HI01-1 ABK ICD-10-CM Diagnosis Code ABF ICD-10-CM Diagnosis Code Principal Diagnosis Code 2300 HI01-2 Admitting Diagnosis Code 2300 HI01-1 ABJ ICD-10-CM Admitting Diagnosis Admitting Diagnosis Code 2300 HI02-2 Patient Reason for Visit Patient Reason for Visit External Cause of Injury External Cause of Injury Other Diagnosis Code 2300 HI01-1, HI02-1, and HI03-1 APR ICD-10-CM Patient s Reason for Visit HI01-2, HI02-2 and HI HI01-1 through HI12-1 ABN ICD-10-CM External Cause of Injury HI01-2 through HI HI01-1 through HI12-1 ABF ICD-10-CM Diagnosis Other Diagnosis Code 2300 HI01-2 through HI12-2 Principal Procedure Code Principal Procedure Code Other Procedure Code 2300 HI01-1 BBR Principal Procedure Code HI HI01-1 through HI12-1 BBQ Other Procedure Codes Other Procedure Code 2300 HI01-2 through HI12-2 * ASC X12/005010X223A2 837 Institutional Claim

11 F. Dental Claim (837 x224a2)* ICD-10 Diagnosis Code 2300 HI01-1 through HI04-1 ABK ICD-10-CM Principal Diagnosis Diagnosis Code * ASC X12/005010X224A2 837 Dental Claim ABF ICD-10-CM Diagnosis HI01-2 through HI04-2 G. Health Care Eligibility Benefit Inquiry (270 X279A1)* Diagnosis Code 2100C HI01-1 through HI08-1 ABK ICD-10-CM Principal Diagnosis Diagnosis Code 2100C HI01-2 through HI08-2 ABF ICD-10-CM Diagnosis Code Procedure Code 2110C EQ02-1 ZZ ICD-10-PCS Procedure Code 2110C EQ02-2 Diagnosis Code 2100D HI01-1 through HI08-1 ABK ICD-10-CM Principal Diagnosis Diagnosis Code 2100D HI01-2 through HI09-2 ABF ICD-10-CM Diagnosis Code Procedure Code 2110D EQ02-1 ZZ ICD-10-PCS Procedure Code 2110D EQ02-2 * ASC X12/005010X279A1 270/271 Health Care Eligibility Request and Response

12 ICD-10 H. Health Care Eligibility Benefit Response (271 X279A1)* Diagnosis Code 2100C HI01-1 through HI08-1 ABK ICD-10-CM Principal Diagnosis Diagnosis Code 2100C HI01-2 through HI08-2 ABF ICD-10-CM Diagnosis Code Procedure Code 2110C EB13-1 ZZ ICD-10-PCS Procedure Code 2110C EB13-2 Procedure Code 2110C EB13-8 Diagnosis Code 2100D HI01-1 through HI08-1 ABK ICD-10-CM Principal Diagnosis Diagnosis Code 2100D HI01-2 through HI08-2 ABF ICD-10-CM Diagnosis Code Procedure Code 2110D EB13-1 ZZ ICD-10-PCS Procedure Code 2110D EB13-2 Procedure Code 2110D EB13-8 * ASC X12/005010X279A1 270/271 Health Care Eligibility Request and Response