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As the health care industry embraces broader use of health IT, many providers are looking to purchase or upgrade their clinical and administrative health IT systems. ICD-10 should be a consideration when choosing either clinical or administrative health IT systems. ICD-10 is the next code set for diagnosis and inpatient procedure coding. The switch to the ICD-10 code set is mandated for October 1,
2015. The new codes will impact many parts of the health care process, from patient referrals to billing and payment. Asking the right questions about ICD-10 will help ensure that a new system will meet your practice’s health IT goals.
ICD-10 DEADLINE
OCT 1, 2015
Questions to Ask Your Practice Management Vendor
Your current health IT vendor may be planning to upgrade your practice management system to function with ICD-10. To check whether a practice management vendor’s ICD-10 upgrades or products will meet your needs, ask vendors these questions:
Will you install products well before the October 1, 2015, deadline, so I can begin testing them in 2014?
Will support for my current products be discontinued after the October 1, 2015, ICD-10 deadline?
When will you update my current products and applications for ICD-10?
Will you provide periodic updates for new products? Will there be a charge for these updates?
Will I need new hardware to accommodate ICD-10-related software changes?
What are the costs associated with maintaining new products?
Will you offer product support? If so, how long will the vendor support the application?
How do I report issues and how quickly will you respond?
Will you provide training on your software?
Will you offer support during and after internal ICD-10 testing?
Will you help me test my system with payers and other trading partners?
Does your product give me the ability to search for codes by the ICD-10 alphabetic and tabular indexes? By clinical concept?
Will your product allow for coding in both ICD-9 and ICD-10 to accommodate transactions with dates of service before October 1, 2015, and transactions with dates of service after October 1, 2015?I061 Rheumatic aortic insufficiency
I062 Rheumatic aortic stenosis with insufficiency I068 Other rheumatic aortic valve diseases
I069 Rheumatic aortic valve disease, unspecified I070 Rheumatic tricuspid stenosis
I071 Rheumatic tricuspid insufficiency
I072 Rheumatic tricuspid stenosis and insufficiency I078 Other rheumatic tricuspid valve dis
Questions to Ask Your EHR Vendor
Clinical health IT systems, such as electronic health records (EHRs), will also need to be compatible with ICD-10 in order to make the most of your health IT investment. When purchasing or upgrading an EHR system, be sure to ask the following questions about ICD-10:
Are your EHR products ICD-10 ready? If not, when will they be?
Can your products help me with the ICD-10 transition? For example, will the products suggest ICD-10 codes based on the clinical data I enter about specific patients?
Do your products map SNOMED-CT to ICD-10 codes to help connect clinical and administrative data?Partner with Your Vendor
After assessing your vendors’ capabilities, continue to work with them throughout the ICD-10 transition. Ask your vendor to share strategies that other clients have used successfully.
For More Information
To learn more about working with vendors and other business partners, consult the ICD-10 resources available on the CMS ICD-10 website.
Official CMS Industry Resources for the ICD-10 Transition
www.cms.gov/ICD10
ICD‐10: FAQs MEDI‐CAL
The federal government has postponed the implementation of ICD‐10 codes in all billing activities pursuant to the Protecting Access
to Medicare Act of 2014, House Resolution 4302, Section 212, Delay in Transition from ICD‐9 to ICD‐10 Code Sets:
“The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD‐10 code sets as the standard for code
sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d–2(c)) and section 162.1002 of title 45, Code of Federal
Regulations.”
On July 31, 2014, the Centers for Medicare & Medicaid Services (CMS) released a final rule that will require ICD‐10 to be
implemented on October 1, 2015, and that will require HIPAA‐covered entities to continue to use ICD‐9 until September 30, 2015.
1. What does International Classification of Diseases, 10th Revision (ICD‐10) compliance mean?
ICD‐10 compliance means that all HIPAA‐covered entities are able to successfully conduct health care transactions on or after
October 1, 2015, using the ICD‐10 diagnosis and procedure codes. ICD‐9 diagnosis and procedure codes can no longer be used for
health care services provided on or after this date.
2. Why is the ICD‐10 transition necessary?
ICD‐10 is a provision of HIPAA, as regulated by the U.S. Department of Health and Human Services (HHS), Centers for Medicare &
Medicaid Services (CMS). This federal mandate pertains to all HIPAA‐covered entities.
The transition from ICD‐9 to ICD‐10 is occurring for the following reasons:
ICD‐9 codes have limited data about patient’s medical conditions and hospital inpatient procedures.
ICD‐9 codes use outdated and obsolete terms and are not consistent with current medical practices.
The structure of ICD‐9 limits the number of new codes that can be created, and many ICD‐9 categories are full. A successful
transition to ICD‐10 is vital to transforming our nation’s health care system.
3. Codes change every year, so why is the transition to ICD‐10 any different from the annual code changes?
ICD‐10 codes are different from ICD‐9 codes in several ways. Currently, ICD‐9 codes are for the most part numeric and have three to
five digits. ICD‐10 codes are alphanumeric and contain three to seven characters. ICD‐10 codes provide a higher level of description.
However, like ICD‐9 codes, ICD‐10 codes will be updated every year.
4. Will ICD‐10 replace Current Procedural Terminology (CPT) procedure coding?
No. The transition to ICD‐10 does not affect CPT coding for outpatient procedures. For hospital inpatient procedures, ICD‐9 codes
will be transitioned to ICD‐10‐PCS (Procedure Coding System).
5. What is the implementation date for ICD‐10?
On October 1, 2015, medical coding in U.S. health care settings will change from ICD‐9 code sets to ICD‐10 code sets.
6. After the October 1, 2015, implementation date, when do I use ICD‐9 versus ICD‐10 on my claim?
Please refer to the chart below, using the date specified in the date field, to determine the ICD code version to use. If the value of
the date field is before October 1, 2015, use ICD‐9 to code the diagnosis. If the value of the date field is on or after October 1, 2015,
use ICD‐10.
Claim Type Claims Date Field To Be Used For Determining ICD Code Version
1 Pharmacy Date of service
2 Long Term Care (LTC) Through date
3 Inpatient Through date
4 Outpatient From date
5 Medical From date
7. Will there be a grace period for converting to ICD‐10?
No.
8. How is Medi‐Cal addressing the implementation of ICD‐10?
Medi‐Cal will be using a crosswalk solution in the legacy California Medicaid Management Information System (CA‐MMIS). Medi‐Cal
has mapped all ICD‐10 codes to corresponding ICD‐9 codes starting with the General Equivalence Mappings (GEMs) provided by the
Centers for Medicare & Medicaid Services (CMS) and modifying the mappings to align with existing Medi‐Cal policy. Claims will be
run against the crosswalk to determine the ICD‐9 value to process through the system. The crosswalk will only be used temporarily
for ICD‐10 claim adjudication while the implementation of our new MMIS system is being completed. Once the new system is online,
Medi‐Cal will adjudicate all claims natively using ICD‐10 and the crosswalk will no longer be used.
9. What is a crosswalk solution?
Medi‐Cal has mapped all ICD‐10 codes to corresponding ICD‐9 codes starting with the General Equivalence Mappings (GEMs) and
Reimbursement Mappings provided by the Centers for Medicare & Medicaid Services (CMS) and modifying the mappings to align
with existing Medi‐Cal policy. Claims that are submitted with ICD‐10 starting October 1, 2015, will run against this crosswalk in order
to identify the appropriate ICD‐9 code that will be used to process the claim. The crosswalk will only be used temporarily for ICD‐10
claim adjudication while the implementation of our new MMIS system is being completed. Once the new system is online, Medi‐Cal
will adjudicate all claims natively using ICD‐10 and the crosswalk will no longer be used.
10. Will an ICD‐10 to ICD‐9 crosswalk be published?
Medi‐Cal will not publish the crosswalk. The crosswalk will not be published since there is already a process for appeal of claim
adjudication where there are disagreements between the amount paid and the amount submitted. However, the provider manuals
will be updated with the ICD‐10 codes as appropriate, allowing providers to refer to the manual for guidance.
11. Who is affected by the transition to ICD‐10? If I don’t deal with Medicare claims, will I have to transition?
Everyone covered by HIPAA must transition to ICD‐10. This includes providers and payers who do not deal with Medicare or
Medicaid claims.
12. What if I don’t make the transition to ICD‐10?
For HIPAA‐covered entities, transition to ICD‐10 is not an option. Claims for all services and hospital inpatient procedures performed
on or after the compliance deadline must use ICD‐10 diagnosis and inpatient procedure codes. This change does not apply to
Current Procedural Terminology (CPT) coding for outpatient procedures. Without ICD‐10, providers will experience delayed
payments or even non‐payments; increased rejected, denied or pending claims; reduced cash flows and ultimately lost revenues.
It is important to note, however, that claims for services and inpatient procedures provided before the compliance date must use
ICD‐9 codes.
13. Is Medi‐Cal policy going to change with ICD‐10?
Medi‐Cal will be updating the provider manuals to account for the change to ICD‐10 in 2015. However, due to the size of the ICD‐10
code set and limitations in the legacy MMIS, policy will not change.
14. Will Medi‐Cal accept claims with both ICD‐10 and ICD‐9 codes on the same claim form?
No. Medi‐Cal will accept claim forms containing only ICD‐9 or ICD‐10 codes.
15. If I transition early to ICD‐10, will Medi‐Cal be able to process my claims?
Pursuant to the CMS final rule issued on July 31, 2014: "This final rule implements section 212 of the Protecting Access to Medicare
Act of 2014 by changing the compliance date for the International Classification of Diseases, 10th Revision, Clinical Modification
(ICD‐10‐CM) for diagnosis coding, including the Official ICD‐10‐CM Guidelines for Coding and Reporting, and the International
Classification of Diseases, 10th Revision, Procedure Coding System (ICD‐10‐PCS) for inpatient hospital procedure coding, including
the Official ICD‐10‐PCS Guidelines for Coding and Reporting, from October 1, 2014 to October 1, 2015. It also requires the continued
use of the International Classification of Diseases, 9th Revision, Clinical Modification, Volumes 1 and 2 (diagnoses), and 3
(procedures) (ICD‐9‐CM), including the Official ICD‐9‐CM Guidelines for Coding and Reporting, through September 30, 2015."
Medi‐Cal will transition to the use of ICD‐10 on October 1, 2015, and early or late transitions will not be allowed.
16. Are paper claims affected by the transition to ICD‐10?
Yes. All claim transactions, whether paper or electronic, except dental claims, will be required to be submitted using ICD‐10 codes.
17. What type of training will providers and staff need for the ICD‐10 transition?
Medi‐Cal will be providing education about the use of ICD‐10 for submitting claims to Medi‐Cal. Providers are encouraged to visit the
Medi‐Cal website regularly throughout the course of the transition to access the latest information about education opportunities.
In addition, ICD‐10 resources and training materials may be available through the Centers for Medicare & Medicaid Services (CMS),
many professional associations and societies, and software/system vendors.
18. Do Treatment Authorization Requests (TARs) that have been approved prior to October 1, 2015 with approval extending past
October 1, 2015, need to be resubmitted with ICD‐10 codes?
No. All active TARs based on the submission of ICD‐9 on or before October 1, 2015, that span the ICD‐10 implementation date will
remain valid. Claims containing ICD‐10 in adherence with the ICD‐10 implementation rules will not be negatively impacted by the
ICD‐9 TAR approvals.
19. When claims are submitted after October 1, 2015, with ICD‐10 codes, for services dated after October 1, 2015, will there be an
impact to claims if the ICD codes versions used (i.e., ICD‐10 or ICD‐9) do not match on the claim and on the TAR (for example, a
TAR with ICD‐9 codes and a claim with ICD‐10 codes)?
No. All active TARs based on the submission of ICD‐9 on or before October 1, 2015, that span the ICD‐10 implementation date will
remain valid. Claims containing ICD‐10 in adherence with the ICD‐10 implementation rules will not be negatively impacted by the
ICD‐9 TAR approvals.
20. Will Treatment Authorization Requests (TARs) require ICD‐10 codes on October 1, 2015?
Yes. Any TAR currently requiring an ICD‐9 diagnosis code will require an ICD‐10 diagnosis code on or after October 1, 2015.
21. Medi‐Cal is proceeding with system changes to prepare for ICD‐10. As a submitter, what changes can I expect prior to October 1,
2015?
Effective September 22, 2014, all claims submitted on the CMS1500, UB04, 25‐1, 30‐1, and 30‐4 will require the entry of an ICD Code
indicator on the claim form specifying the submission of ICD‐9 or ICD‐10 with the exception of the Confidential Screening/Billing
Report (PM 160) claim form, which will not include an indicator. Submitters are expected to provide ICD‐9 codes and use the ICD‐9
indicator on claims until the transition to ICD‐10 on October 1, 2015.
Also effective September 22, 2014, all electronic TARs (eTAR) forms will require the inclusion of the ICD code indicator and ICD code.
Paper TARs submitted on 18‐1, 18‐2, 18‐3, 20‐1, 50‐1, 50‐2, and 50‐3 will require an ICD code on the submission. A diagnosis
description in lieu of the diagnosis code will no longer be accepted on eTAR or paper TAR submissions.
22. Where can I get additional information about ICD‐10?
More information about ICD‐10 is available on the ICD‐10 page of the CMS website.
Providers may also submit ICD‐10‐related questions to the ICD‐10 mailbox at ICD‐10Medi‐[email protected].
ICD-10 Resources
ICD-10 Basics
These basic resources include overviews of ICD-10 tailored by audience. All resources are available through the CMS ICD-10 website, cms.gov/ICD10:
• The ICD-10 Transition: An Introduction
• ICD-10 Basics for Medical Practices
• ICD-10 Basics for Small and Rural Practices
• ICD-10 Basics for Payers
• The ICD-10 Transition: Focus on Non–Covered Entities
Communicating About ICD-10
Communication between health care providers, software vendors, clearinghouses, and billing services is an important part of the transition process. Learn how to get the conversation started with these resources:
• Talking to Your Vendors About ICD-10: Tips for Medical Practices
• Questions to Ask Your Systems Vendors about ICD-10
• The Role of Clearinghouses in ICD-10
• Talking to Your Customers About ICD-10: Tips for Software Vendors
Road to 10
Available on the Provider Resources page of www.cms.gov/ICD10, the “Road to 10” tool is an online resource
built with the help of providers in small practices. This tool is intended to help small medical practices jumpstart their ICD-10 transition and includes specialty references, webcast series, and the capability to build ICD-10
action plans tailored for their practice needs. Watch this brief video for an explanation of the benefits of ICD-10
and an overview of the “Road to 10” tool.
ICD-10 Email Update Messages
CMS distributes regular Email Update messages with information about ICD-10. Past messages include:
• ICD-10 Testing Opportunities for Medicare FFS Providers
• Deadline for ICD-10 Allows Health Care Industry Ample Time to Prepare for Change
• CMS Releases ICD-10 Training and Preparation Webcast
Medscape Education Modules
Medscape Education Modules offer an overview of ICD-10 tailored for small practices. Continuing medical education (CME) and continuing education (CE) credits are available to physicians and nurses who complete the learning modules, but anyone with a free account can take them and receive a certificate of completion. Modules are available on the CMS ICD-10 website.
• Video: ICD-10: Getting From Here to There -- Navigating the Road Ahead
• Video: ICD-10 and Clinical Documentation
• Expert Column: Preparing for ICD-10: Now Is the Time
Stay up to date on ICD-10!
• Sign up for Email Update messages