International Classification of
Diseases (ICD)-10:
Provider community ICD-10 compliance
What you can expect from us
Frequently asked questions
Available provider resources
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 10/1/2015.
• 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,
2015.
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.
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.
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).
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, 2015.
Differences Between ICD-9 and ICD-10
ICD-9 Diagnosis Codes
ICD-10 Diagnosis Codes
No laterality
Laterality –
Right or left account for > 40% of codes
Three-five digits
First digit is alpha (E or V) or numeric
Digits two-five are numeric
Decimal is placed after the third character
Seven digits
Digit one is alpha; digit two is numeric
Digits three-seven are alpha or numeric
Decimal is placed after the third character
No placeholder characters
“X” placeholders
14,000 codes
69,000 codes to better capture specificity
Limited severity parameters
Extensive severity parameters
Limited combination codes
Extensive combination codes to better
capture complexity
1
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
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)
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
What Does All This Mean?
Before the Compliance Date
After the Compliance Date
821.11
Open fracture of shaft of
femur
S72.351C
Displaced comminuted
fracture of shaft of right femur,
initial encounter for open
fracture type IIIA, IIIB or IIIC
What Does All This Mean?
Common Conditions Coded from ICD-9 to
ICD-10: Family Practice
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
®
)
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!
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!
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 ManagerSM is available to submit claims at
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
Inpatient Claims
Admission and
discharge dates
before 10/1/2015
You should
file claims
with ICD-9
codes
Admission date
before 10/1/2015
and discharge date
after 10/1/2015
You should
file claims
with ICD-10
codes
Admission and
discharge date on
or after 10/1/2015
You should
file claims
with ICD-10
codes
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
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 10/1/2015.
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.
Testing
BlueCross BlueShield of South Carolina and
BlueChoice HealthPlan began ICD-10 testing with
our South Carolina providers in April 2015.
•
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.
Testing
For more information about ICD-10 testing with
BlueCross and BlueChoice, please email
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
www.SouthCarolinaBlues.com and
www.BlueChoiceSC.com for additional
ICD-10 FAQs.
Questions & Answers
Your Question Our Answer
What should I do if our claims are continually rejected or denied for ICD-10 coding?
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?
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.
If we submit the wrong ICD-10 code, will we get a grace
period to put in the right one?
You can submit a corrected claim just as you do today.
Questions & Answers
Your Question Our Answer
Will you base the necessary codes for claims on the date submitted or the DOS ?
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.
Will our claims reject if we submit RT/LT modifiers?
We still require modifiers (including RT/LT) on procedure codes even if the diagnosis code specifies laterality. We did not change procedure code requirements.
Do we need to update
diagnosis codes for existing authorizations for ongoing services?
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.
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?
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.
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?
Yes. If you change the DOS to a later date after ICD-10-CM implementation, you will need to get a new authorization.
Questions & Answers
Your Question Our Answer
Is there going to be a new CMS 1500 form?
According to the CMS, it will accept only the
revised 02-12 CMS-1500 form as of April 1, 2014. CMS has not indicated a revision to the current form. You can visit www.CMS.gov for additional information.
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?
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 (www.wpc-edi.com) provides hardcopy manuals for a cost. You can also visit www.ICD10Data.com, 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
Questions & Answers
Your Question Our Answer
Will diagnosis and procedure codes change or remain the same?
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.
Do you process claims by DOS or date of claim
submission?
We process claims by DOS.
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?
Yes. If you change the DOS to a later date after ICD-10-CM implementation, you will need to get a new authorization.
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?
You should always request the diagnosis code when getting an 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.
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.
Questions & Answers
Your Question Our Answer
Does the ICD-10-CM affect dental codes at all?
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.
Will BlueCross require
external mechanism codes on a claim when we submit ICD-10-CM codes for fractures, sprains or strains?
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
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 814.09 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.
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-1500 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
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?
We will add bulletins to
www.SouthCarolinaBlues.com and
www.BlueChoiceSC.com. Our Provider Services call center will also include any ICD-10-CM
announcements via the voice response unit (VRU).
Are we allowed to submit ICD-9 and ICD-10-CM codes
together on a claim?
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.
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.
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?
DSM-5 contains both ICD-9-CM and ICD-10-CM codes.
Will there be a grace period to update the level of care on an authorization?
You should update the level of care on an authorization as soon as possible.
Do you require medical records for authorizations if we don’t know the specific diagnosis code?
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
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
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 389.17 and 389.18. 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 www.icd10data.com 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 389.17; and ICD-10-CM H90.3 for ICD-9-CM 389.18.
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.
Resources
•
www.hipaacriticalcenter.com/icd10.aspx
•
www.cms.gov/Medicare/Coding/ICD10/download
s/ICD-10MythsandFacts.pdf
•
www.cms.gov/Medicare/Coding/ICD10/Download
s/ICD10Introduction20140819.pdf
•
www.cms.gov/Medicare/Coding/ICD10/Clarifying
-Questions-and-Answers-Related-to-the-July-6-2015-CMS-AMA-Joint-Announcement.pdf
Additional Information
Name
Area
Telephone Email
Contessa Struckman Provider Education 803-264-3481 [email protected] Shamia Gadsden Provider Education 803-264-6966 [email protected]
Ashlie Graves Provider Education 803-264-4301 [email protected] Jada Addison Provider Education 803-264-2724 [email protected] Mary Ann Shipley Provider Education 803-264-3724 [email protected] Sandy Sullivan Provider Education 803-264-5969 [email protected] Sharman Williams Provider Education 803-264-8425 [email protected]
Bunny Thomas Provider Education 803-264-1701 [email protected] Elizabeth Duvall Provider Education 803-264-6826 [email protected]
Resources
Name
Area
Telephone
Teosha Harrison Manager, Provider
Relations & Education 803-264-4364 [email protected] Bart Strickland Director, EDI Services N/A [email protected]
Kim Lewis Manager, EDI Services N/A [email protected] Mark Harder Business Analyst, EDI
Services N/A [email protected]
ICD-10 Testing N/A [email protected]
