ICD-10 implementation

On July 31, U.S. Department of Health and Human Services issued a Final Rule formally setting an Oct. 1, 2015, compliance date for conversion to ICD-10 diagnostic and procedure codes.

Frequently asked questions

What is ICD-10?

ICD-10-CM is the United States’ clinical modification of the World Health Organization’s (WHO) International Classification of Diseases (ICD) Tenth Revision. It is used to classify diseases and causes of illness recorded on health records, claims, and other vital information. ICD-10-PCS is the procedure classification system that is used to report hospital inpatient procedures. The transition to ICD-10 code sets does not affect the Current Procedural Terminology (CPT®) code set, which will continue to be used for outpatient services.

The Department of Health and Human Services adopted a rule in 2009 that requires covered entities (health plans, health care providers, and health care clearinghouses) to move from ICD-9 to the next generation ICD-10 code sets. In July 2014, a final rule was announced establishing the ICD-10 compliance date as October 1, 2015. All covered entities must comply with ICD-10 by this new date of October 1, 2015.

When is the ICD-10 compliance date?

On July 31, 2014, the Department of Health and Human Services issued a final rule formally setting an October 1, 2015 compliance date for conversion to ICD-10 diagnostic and procedure codes. This means that health plans, health care providers, and health care clearinghouses that transact standard health care transactions must use ICD-10-CM diagnosis codes for services occurring on or after October 1, 2015 and ICD-10-PCS procedure codes for discharges occurring on or after October 1, 2015.

Based on this compliance date, we will resume direct testing with our providers and trading partners in early 2015. This testing is optional for our providers. If interested, check back with our website for updated information on how to begin the testing process.

What is the health plan doing to ensure a smooth transition from ICD-9 to ICD-10?

The health plan's ICD-10 transition project includes:

  • Working with providers and partners to implement the ICD-10 conversion.
  • Mapping of current ICD-9 codes to ICD-10 as well as ICD-10 to ICD-9 codes (completed).
  • Appropriate updates to our policies, rules, and system configuration.
  • A comprehensive end-to-end testing strategy.
  • Training and education for employees and providers
  • Closely collaborating with covered entities within Massachusetts, including providers, other payers and clearinghouses to ensure a smooth transition through comprehensive testing and education efforts

How will ICD-10 affect the health plan’s policies?

We have conducted a thorough evaluation of our medical and payment policies. Where applicable, policies were updated; policies currently list both ICD-9 and ICD-10 codes. The ICD-9 codes will be removed from policies after the transition to ICD-10 is complete.

Will the health plan conduct ICD-10 testing with providers?

Yes, we will conduct testing with providers. We successfully tested with and transitioned all trading partners to 5010 which allowed us to be ready for ICD-10. We are not requiring Trading Partners to retest for ICD-10. However, if providers would like to test with us, they are welcome to do so by contacting their EDI Coordinator as soon as possible to schedule this testing:

Does the change to ICD-10 codes have any impact on CPT codes?

No, there is no impact on CPT codes.

Will the plan follow CMS’ one-year grace period in which it will reimburse Medicare Part B providers for claims not billed to the highest specificity ICD-10 codes?

No. Our expectation is for providers to code to the highest level of specificity supported by the medical documentation.

Will the plan accept unspecified ICD-10 codes?

Currently, the plan is not supportive of the unspecified diagnostic codes being utilized in lieu of valid diagnostic information. If a provider receives invalid, missing or illegible diagnostic codes for tests from ordering physicians, we respectfully request that the provider consult with the respective physicians for accurate ICD-9 and/or ICD-10 codes. This will ensure that the provider’s claims are processed timely and accurately based on submitted claim information.

Will the ICD-10 conversion impact provider contracting?

After concluding our internal preparation for the ICD-10 conversion, we are committed to ensuring provider reimbursement continues without disruption during the transition period in the coming months. Beginning in May 2015, we will also partner directly with those providers whose contracts are financially impacted through a few testing approaches to maintain mutual financial neutrality. We will review the testing options with providers to determine a mutually agreeable approach.

Will the plan accept ICD-9 codes for services requiring authorization that occur on or after 10/1/2015?

We will not accept ICD-9 codes for services that occur on or after 10/1/2015. Authorization requests for services on or after 10/1/2015 should include the ICD-10 codes.

Will you be able to accept ICD-10 codes on authorizations before 10/1? If so, when?

Yes, we are now accepting ICD-10 codes on authorizations for services starting on or after 10/1/15

How do I submit claims with a date of service that starts before 10/1/2015 and ends on or after 10/1/2015?

You will need to submit the claim according to when the service was rendered (date of service).

NOTE: Rules are different for outpatient facility and professional versus inpatient facility claims.

FACILITY CLAIMS

Inpatient claims: Code the claim according to the date of discharge; do not split the claim.

  • If the patient was discharged through 09/30/2015, then submit using ICD-9 codes, for the entire length of stay.
  • If the patient was discharged on or after 10/1/2015, then submit using ICD-10 codes, for the entire length of stay.

Observation claims: Code the claim according to the date of discharge; do not split the claim.

  • If the patient was discharged through 09/30/2015, then submit using ICD-9 codes, for the entire length of stay.
  • If the patient was discharged on or after 10/1/2015, then submit using ICD-10 codes, for the entire length of stay.

E\R claims: Code the claim according to the date of discharge; do not split the claim.

  • If the patient was discharged through 09/30/2015, then submit using ICD-9 codes, for the entire length of stay.
  • If the patient was discharged on or after 10/1/2015, then submit using ICD-10 codes, for the entire length of stay.

NOTE: If the patient arrived through the E\R and was then admitted, the entire claim will roll up as an inpatient stay. Likewise for observation, if the patient was under observation and subsequently, admitted, the entire stay will be rolled up as an inpatient stay.

Outpatient Facility (i.e. Same Day Surgery):

  • For services rendered through 9/30/15, submit one claim with ICD-9 codes.  
  • For services rendered on 10/1/2015 or after, a second claim should be submitted with ICD-10 codes.

Durable Medical Equipment:

  • If the rental period being billed starts on or prior to 9/30/15, submit claim with ICD-9 codes.
  • If the rental period being billed starts on or after 10/1/15, submit claim with ICD-10 codes.
  • Please do not split the claims; rather submit based on the rental period start date.

PROFESSIONAL CLAIMS

If the provider typically bills multiple dates of service on one outpatient claim that crosses over the ICD-10 implementation date (10/1/2015), the claim will need to be split according to dates of service (services through 9/30/15 on one claim and on/after 10/1/2015 on a second claim).

Will you accept 837 batches with both ICD-9 and ICD-10 claims spanning the conversion deadline?

Yes, 837 batches will be accepted with both ICD-9 and ICD-10 claims as long as both codes are not on the same claim.

Will claims that don’t meet specifications be rejected at point of receipt or will a denial be issued?

Denials will be issued on claims that do not meet the specifications.

In the event of issues directly related to the ICD-10 transition, how will you assist providers?

Providers can work with their dedicated contract managers to implement short-term resolutions, including waiving the claims filing limit and extending the provider appeal filing limit through the transition.

What process or action is the health plan taking to guarantee revenue losses will not occur during the ICD-10 transition?

We are committed to working with providers prior to the go-live date to ensure the transition is seamless and operational issues have been resolved. The plan is willing to extend claim file limits and provider appeals filing limits.

Will the health plan share ICD-9 to ICD-10 mappings?

We will share ICD-9 to ICD-10 mappings upon request. For more information, contact your Provider Relations representative at 1-866-275-3247, option 4.

Where can I get more information about ICD-10?

The following websites offer additional information about ICD-10:


Who can I contact with additional questions about Fallon Health Weinberg's ICD-10 conversion?

If you have any questions, contact the Provider Service Line at 1-855-827-2003, or you can email us at:AskFHW@fallonweinberg.org

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