Emdeon Clearinghouse ICD-10 Frequently Asked Questions Published Q1 2013 Re-Published Q2 2014
Preface This information is provided by Emdeon for education and awareness use only. Even though Emdeon believes that all the information in this document is correct as of the date of the publication of this version, Emdeon does not warrant the accuracy, completeness, or fitness for any particular purpose of this information. All use is at the reader s own risk. 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 Emdeon. 2012, 2013, 2014 Emdeon Business Services LLC, 3055 Lebanon Pike Suite 1000, Nashville, TN 37214. All Rights Reserved. Printed in the USA.
Contents Readiness and Planning... 4 ICD Code Utilization... 4 Cross-Walking Position... 6 Clearinghouse Edits... 6 Customer Impact... 8 External Testing Approach... 9
Readiness and Planning Q: What is the Emdeon Clearinghouse timeline and status for completing ICD-10 analysis, design, and remediation efforts? A: Remediation was completed in Q2, 2013. Additional payer specific clearinghouse edits may be implemented upon payer request. Q: When do you expect to start ICD-10 testing? A: Emdeon s Clearinghouse has completed internal testing. External testing in a controlled and limited pilot setting began in Q2 2012. The Emdeon Testing Exchange for ICD-10 was released as generally available in August of 2013 for all Emdeon Provider, Channel Partner, and Payer customers. ICD Code Utilization Q: How does the Emdeon Clearinghouse currently address ICD-9 diagnosis and procedure codes? A: Emdeon as a clearinghouse validates that the codes submitted are syntactically correct and are valid ICD-9 codes with a valid qualifier. In our role as a clearinghouse, Emdeon is not involved in the code assignment or payment determination of the claim. Q: Does the Emdeon Clearinghouse plan to support the processing of both ICD-9 and ICD-10 claims sent by customers after the compliance date? A: Emdeon will send submitted ICD-9 and ICD-10 valid codes to payers, allowing them to accept or reject based on their business practice. Upon payer request, Emdeon will validate proper code sets are submitted based on the service/discharge dates. Q: For claim files sent to the Emdeon Clearinghouse by customers, does Emdeon have the capability to differentiate ICD-9 and ICD-10 claims in the same file?
A: On and after the compliance date, claim files can contain a mix of both ICD-9 and ICD-10 coded claims. Providers should utilize the appropriate ICD qualifier to distinguish between ICD-9 and ICD-10 code submissions. Q: Will the Emdeon Clearinghouse support ICD-10 codes prior to the compliance date? A: At this time, ICD-10 codes received in production prior to the compliance date will be rejected. Early adoption of ICD-10 for providers and payers will not be supported unless allowed as a result of the new HHS regulation. Q: Will the Emdeon Clearinghouse no longer support ICD-9 codes after the compliance date? A: Emdeon expects that there will be late filings and adjustments which will require ICD-9 codes for service dates or discharge dates that are prior to the compliance date. ICD-9 codes will continue to be supported for: Non-covered entities (i.e. Workers Compensation), corrected, resubmitted, run-out claims, secondary (COB), subrogation claims, and as instructed per payer requirements or contingency plans. Q: Will the Emdeon Clearinghouse continue to support legacy formats such as ASC X12 version 4010 and NSF for providers or payers who do not convert to ASC X12 version 5010? A: Emdeon Clearinghouse customers are required to support the HIPAA version 5010 transaction standards which enable ICD-10 data content. Q: How does the revised 02/12 1500 health insurance claim form support ICD-10? A: The revised 1500 paper claim form, among other changes, notably adds the following functionality: - Indicators for differentiating between ICD-9-CM and ICD-10-CM diagnosis codes. - Expansion of the number of possible diagnosis codes to 12. - Qualifiers to identify the following provider roles (on Item 17): o Ordering o Referring o Supervising
See the 1500 Health Insurance Claim Form Change Log for a list of all form changes. Cross-Walking Position Q: Will the Emdeon Clearinghouse cross walk ICD-10 codes to ICD-9 codes, or ICD-9 codes to ICD-10 codes? A: Emdeon s standard offering will not include cross-walking to and from ICD-10. Emdeon will pass valid ICD-9 claims to payers without translation to ICD-10 and will pass valid ICD-10 claims to payers without translation to ICD-9. If provided, Emdeon will convey payer claim status messaging of rejected or denied ICD-9 or ICD-10 claims to the originating provider. Clearinghouse Edits Q: What level of editing does the Emdeon Clearinghouse plan on performing on or after the compliance date? A: Emdeon will offer several edit options for validating ICD-10-CM and ICD-10- PCS codes to support payer requirements. Some edits are standard, and will be applied to all claims. Other edits will be made available upon request of the payer. Please contact your Emdeon Account Management representative to discuss request-based edits. For Professional and Institutional Claims - ASC X12N 837 v5010 Default Edits: (unless otherwise instructed by payer) Valid Qualifier Emdeon will reject if the Procedure Code and Diagnosis Code Qualifiers are not valid. ICD-10 acceptance Emdeon will reject claims containing ICD-10 codes prior to the compliance date. Valid Inpatient Procedure Codes Emdeon will continue to validate the codes based on the qualifier; if the qualifier indicates ICD-9 then the code must be a valid ICD-9 code; if the qualifier indicates ICD-10-PCS then the code must be a valid ICD-10-PCS code. Valid Diagnosis Codes Emdeon will continue to validate the codes based on the qualifier; if the qualifier indicates ICD-9-CM then the
code must be a valid ICD-9-CM code; if the qualifier indicates ICD-10-CM then the code must be a valid ICD-10-CM code. Note: Diagnosis code edits include Principal, Admission, Patient Reason for Visit, External Cause of Injury and Other diagnosis code fields. Diagnosis Type Code qualifier must be appropriate for the ICD code value submitted. ICD-9 and ICD-10 within the same claim Emdeon will follow CMS guidance and reject claims that contain a mix of ICD-9 and ICD-10 codes in the same claim. ICD-10 edits activated upon Payer request/instruction: Any payer specific edits currently in place will be carried forward once confirmed with the payer. Suppress any Default Edits specified above including ICD code set editing. Payer inability to accept ICD-10 (including the inability to accept ASC X12N v5010). Compliance Date Edit- If the service/discharge date is prior to the compliance date it must be a valid ICD-9 code; if the service/discharge date is on or after the compliance date it must be a valid ICD-10 code.. Perform advanced code set editing based on payer requirements/instruction. Most specific diagnosis codes allows Payer to have Emdeon reject claims with a code that is not the most specific. Note: Reference to ASC X12N 5010 includes any applicable errata Q: Will the Emdeon Clearinghouse require ICD-10 based on the service/discharge date on or after the compliance date? A: Emdeon s standard approach, consistent with the level of editing performed for ICD-9, will be to validate that the codes submitted are syntactically correct and are valid code values for the type of code submitted (ICD-9 vs. ICD-10). If a provider sends an ICD-9 code with an ICD-9 qualifier after the ICD-10 compliance date, and the code is valid, Emdeon will pass the claim on to the payer unless otherwise instructed. This approach provides payer visibility as to which providers are continuing to use ICD-9 codes. Q: How will the Emdeon Clearinghouse distinguish an ICD-9 code vs. an ICD-10 code?
A: Providers are expected to utilize the appropriate ICD qualifier (Diagnosis Type Code within the ASC X12 v5010 standard). Emdeon will use the ICD qualifier to distinguish between ICD-9 and ICD-10 code submissions. Q: Will the Emdeon Clearinghouse allow both ICD-9 and ICD-10 codes on the same claim? A: No, Per CMS Guidance, both ICD-9 and ICD-10 codes cannot be submitted within the same claim. Claim files can contain ICD-9 coded claims and ICD-10 coded claims, but an individual claim cannot contain both ICD-9 and ICD-10 codes. Emdeon will reject claims containing both ICD-9 and ICD-10 diagnosis codes and/or procedure codes. Dates of Service that span the compliance date must be split into separate claims to ensure both ICD-9 and ICD-10 codes are not represented on the same claim. Customer Impact Q: Does the Emdeon Clearinghouse anticipate any pricing changes (financial or contractual impact) to the Emdeon Clearinghouse services due to ICD-10 implementation? A: There will be no pricing changes specifically related to ICD-10 for existing clearinghouse services. Consulting services, value-add reporting, and contingency solutions are separately priced, billable and contracted services. Q: Will customer support and training be provided for ICD-10? Is there a charge? A: Support will remain unchanged for Emdeon s clearinghouse support services. As is currently the case with ICD-9, Emdeon clearinghouse support is not prepared to address questions that are clinical or code set in nature and cannot assist with the appropriate ICD-10 coding of transactions. Q: Are there any new hardware or software requirements associated with ICD-10? A: Please consult your software vendor to understand ICD-10 hardware and softare requirements for your practice management software.
External Testing Approach Q: When will Emdeon be ready for external customer testing? A: Emdeon is ready to test with all external customers as of August 2013 via the Emdeon Testing Exchange for ICD-10: - Emdeon continues its leadership in healthcare by offering the first selfservice ICD-10 testing exchange in the industry providing a free, realistic and approachable testing pathway - Enables submitters/providers to send ICD-10 coded test claims and receive clearinghouse feedback for ALL Emdeon payers - Enables payers to request accepted provider/submitter sourced ICD-10 test claims self service via the Emdeon ON 24/7 portal - Utilizes established submitter identifiers and communication method(s) to make the test claim submission and feedback process simple. There is no additional software to configure or buy - The Emdeon testing exchange for ICD-10 is offered to our provider, partner, and payer customers at no charge - Additional materials to help guide Emdeon customers in getting started are available at Emdeon s one-stop resource center, HIPAA Simplified, which supports organizations preparing for regulatory mandates Q: What are your plans for testing claims containing ICD-10 codes? How will you involve your clients in that process? A: Please see the outline below representing the Emdeon Testing Exchange for ICD-10 workflow: 1. Provider collaborates with payer to discuss test data criteria, scenarios, and expected outcomes 2. Providers send Emdeon their ICD-10 coded professional and institutional test claims in the X12N 837 v5010 format, using a T test indicator value in the ISA-15 header and submit using their existing Emdeon Exchange trading partner identifiers and communication method 3. Emdeon provides clearinghouse feedback through your established test setup and reporting preferences 4. Emdeon compiles and stores accepted ICD-10 coded test claims to make them available to participating payers upon their request
5. Payers request ICD-10 test claims from a pool of accepted Provider test data, via the Emdeon ON24/7 portal 6. Emdeon sends accepted ICD-10 test claims in an aggregated X12N 837 v5010 Institutional or Professional claim file per payer s request. Test files will include all of the established receiver identifiers, batching requirements, etc. required for further payer processing & testing 7. Payer collaborates with the Provider outside of the Emdeon testing pathway to share payer processing and payment results. Because the transition to ICD-10 is data content specific, Emdeon promotes conversational collaboration between providers and payers to discuss test data criteria, scenarios, and outcomes. Q: Will Emdeon support end-to-end testing? A: In a limited and controlled environment, Emdeon will consider end-to-end testing to the degree possible for trading partners. Emdeon has observed that ICD-10 testing can be a very manual process with inconsistencies in workflow, environments, and automation capabilities. Emdeon is committed to continuing work with industry leaders and customers in exploring and developing cost-effective testing models, including end-to-end testing, to support current and future regulatory requirements. Q: What are the challenges in supporting test payment feedback in a production-like manner? A: This is an industry-wide challenge and not specific to Emdeon. The infrastructure required to support production-like end-to-end testing activities is very immature within the industry and will require substantial investment, setup, ongoing maintenance, and administrative costs. - Not all payers will be able to provide test systems capable of supporting test payment feedback in the X12 835 standard. - Payers may require unique comm connections for ICD-10 testing purposes requiring manual transmission. - Emdeon, as a submitting clearinghouse, may not be the payment feedback clearinghouse for a given trading partner. - Many providers POMIS or HIS systems are not capable of creating test transactions and/or receiving and processing testing feedback. - Many providers utilize ancillary value-add products in the claiming and posting process that would need to be considered during testing.
Variances in testing approaches between participants such as timing, unique testing and data requirements, and limited provider participation add additional challenges. For example some payers limit the number of test claims and number of providers, while others may specify claim types, scenarios and date ranges. Most importantly, testing outcomes may vary due to more specificity in the codes, highlighting areas where providers may not have been coding correctly in ICD9 or where clinical information is not sufficient to support ICD10 coding. Payers also use various methods to communicate testing feedback to Providers. These may include web based applications, proprietary reporting, paper remits and other human readable reporting in addition to the standard X12 835 remittance advice. Testing also introduces challenges in reconciling the number of claims submitted - to the feedback received. This is often due to claims being split, bundled and/or pended. In addition, the feedback may not be as expected due to the payer production and testing environments being out of synch for benefit accumulators, member and provider eligibility, policies, and fee schedules. And finally, there are various technologies and tools used by providers to accept and process payer feedback. Some are limited in their ability to process test feedback in existing accounting systems. The feedback may include an 835 in its native machine readable state making it difficult for providers to interpret without the needed tools and/or systems. Identified variances will require conversational collaboration as ICD-10 coding behaviors and processing workflow may inherently differ from current ICD-9 practice. This can only be resolved between providers and payers. Q: Will Emdeon support parallel ICD-9 and ICD-10 coded claims for testing purposes? A: The Emdeon Testing Exchange for ICD-10 does not support the same claim coded both as ICD-9 and ICD-10 for delivery via the Testing Exchange. Payers should have access to the ICD-9 coded claim previously received in Production, and can reference as needed for parallel testing purposes. Emdeon is a leading provider of revenue and payment cycle management and clinical information exchange solutions, connecting payers, providers, and patients in the U.S. Healthcare system. Emdeon s product and service offerings integrate and automate key business and administrative functions of its payer and provider customers throughout the patient encounter. Through the use of Emdeon s comprehensive suite of products and services, which are designed to easily integrate with existing technology infrastructures, customers are able to improve efficiency, reduce costs, increase cash flow and more efficiently manage the complex revenue and payment cycle and clinical information exchange processes. For more information, visit www.emdeon.com. 2013, 2014 Emdeon Business Services LLC. All rights reserved. 3055 Lebanon Pike, Suite 1000 Nashville, TN 37214-2230 877.EMDEON.6 (877.363.3666) www.emdeon.com