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

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WEDI Strategic National Implementation Process (WEDI SNIP) ICD-10 Workgroup

ICD-10 Issue Brief

ICD-10 Impact to HIPAA Transactions June 7, 2013

Workgroup for Electronic Data Interchange

1984 Isaac Newton Square, Suite 304, Reston, VA. 20190 T: 202-684-7794//F: 202-318-4812

Accredited Standards Committee (ASC) X12, Incorporated

241 East Fourth Street, Unit 202, Frederick, MD 21701 T: 301.685.6517 x 101

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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-10 ... 7

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)* ... 10

F. Dental Claim (837 x224A2)* ... 11

G. Health Care Eligibility Benefit Inquiry (270 X279A1)* ... 11

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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).

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ICD-10

Impact to HIPAA Transactions

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.

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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) X222A1

Health Care Claim: Institutional (837) X221A2

Health Care Claim: Dental (837) X224A2

Health Care Services Review – Request for Review and Response (278) X217 Health Care Eligibility Benefit Inquiry and Response (270/271) X279

Benefit Enrollment and Maintenance (834) 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) X221A1

Health Care Claim Status Request and Response (276/277) X212 Payroll Deducted and Other Group Premium Payment for Insurance

Products (820) 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.

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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)*

Element Name Loop Segment/Data Element

Patient Diagnosis Qualifier 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 Qualifier

2000E CR610

No ICD-10-PCS available in 5010.

Surgical Procedure Code 2000E CR611

Procedure Code Qualifier 2000E SV202-1

ZZ – ICD-10-PCS Procedure Code 2000E SV202-2

Procedure Code 2000E SV202-8

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ICD-10

Impact to HIPAA Transactions B. Health Care Services Review Response (278 X217)*

Patient Diagnosis Qualifier 2000E HI01-1 through HI12-1 Patient Diagnosis Qualifier

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 Qualifier

2000E CR610 Medical Code

Surgical Procedure Code 2000E CR611 Medical Code

Procedure Code Qualifier 2000E SV202-1

ZZ – ICD-10-PCS Procedure Code 2000E SV202-2

Procedure Code 2000E SV202-8

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ICD-10

Impact to HIPAA Transactions C. Benefit and Enrollment (834 X220A1)*

Diagnosis Code Qualifier 2200 DSB07

ZZ – ICD-10-CM Diagnosis Code 2200 DSB08

D. Professional Claim (837 X222A1)*

Diagnosis Code Qualifier 2300 HI01-1 through HI12-1 Diagnosis Code Qualifier

ABK – ICD-10-CM Principal Diagnosis ABF – ICD-10-CM Diagnosis

Diagnosis Code 2300 HI01-2 through HI12-2 Diagnosis Code

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ICD-10

Impact to HIPAA Transactions E. Institutional Claim (837 X223A2)*

Principal Diagnosis Code Qualifier

2300 HI01-1

ABK – ICD-10-CM Diagnosis Code ABF – ICD-10-CM Diagnosis Code Principal Diagnosis Code 2300 HI01-2

Admitting Diagnosis Code Qualifier

2300 HI01-1

ABJ – ICD-10-CM Admitting Diagnosis Admitting Diagnosis Code 2300 HI02-2

Patient Reason for Visit Qualifier

2300 HI01-1, HI02-1, and HI03-1

APR – ICD-10-CM Patient’s Reason for Visit

Patient Reason for Visit HI01-2, HI02-2 and HI03-2

External Cause of Injury Qualifier

2300 HI01-1 through HI12-1

ABN – ICD-10-CM External Cause of Injury

External Cause of Injury HI01-2 through HI12-2

Other Diagnosis Code Qualifier

ABF – ICD-10-CM Diagnosis Other Diagnosis Code 2300 HI01-2 through HI12-2

Principal Procedure Code Qualifier

2300 HI01-1

BBR – Principal Procedure Code Principal Procedure Code HI01-2

Other Procedure Code Qualifier

BBQ – Other Procedure Codes Other Procedure Code 2300 HI01-2 through HI12-2

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ICD-10

Impact to HIPAA Transactions F. Dental Claim (837 x224A2)*

Diagnosis Code Qualifier 2300 HI01-1 through HI04-1

ABK – ICD-10-CM Principal Diagnosis ABF – ICD-10-CM Diagnosis

G. Health Care Eligibility Benefit Inquiry (270 X279A1)*

Diagnosis Code Qualifier 2100C HI01-1 through HI08-1

ABK – ICD-10-CM Principal Diagnosis ABF – ICD-10-CM Diagnosis Code Diagnosis Code 2100C HI01-2 through HI08-2

Procedure Code Qualifier 2110C EQ02-1

ZZ – ICD-10-PCS Procedure Code 2110C EQ02-2

Diagnosis Code Qualifier 2100D HI01-1 through HI08-1

ABK – ICD-10-CM Principal Diagnosis ABF – ICD-10-CM Diagnosis Code Diagnosis Code 2100D HI01-2 through HI09-2

Procedure Code Qualifier 2110D EQ02-1

ZZ – ICD-10-PCS Procedure Code 2110D EQ02-2

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ICD-10

H. Health Care Eligibility Benefit Response (271 X279A1)*

Diagnosis Code Qualifier 2100C HI01-1 through HI08-1

ABK – ICD-10-CM Principal Diagnosis ABF – ICD-10-CM Diagnosis Code Diagnosis Code 2100C HI01-2 through HI08-2

Procedure Code Qualifier 2110C EB13-1

ZZ – ICD-10-PCS Procedure Code 2110C EB13-2

Procedure Code 2110C EB13-8

Diagnosis Code Qualifier 2100D HI01-1 through HI08-1

ABK – ICD-10-CM Principal Diagnosis ABF – ICD-10-CM Diagnosis Code Diagnosis Code 2100D HI01-2 through HI08-2

Procedure Code Qualifier 2110D EB13-1

ZZ – ICD-10-PCS Procedure Code 2110D EB13-2

Procedure Code 2110D EB13-8