Blue Choice

South Carolina Healthy Connections

ICD-10 FAQs

What is ICD-10?

International Classification of Diseases, 10th Revision (ICD-10) is a diagnostic and procedure coding system endorsed by the World Health Organization (WHO) in 1990. It replaces the International Classification of Diseases, 9th Revision (ICD-9), which was developed in the 1970s. Internationally, the codes are used to study health conditions and assess health management and clinical processes; and in the United States, the codes are the foundation for documenting the diagnosis and associated services provided across health care settings.

Although we often use the term ICD-10 alone, there are actually two parts to ICD-10:

  • ICD-10-CM (Clinical Modification) used for diagnosis coding,
  • ICD-10-PCS (Procedure Coding System) used for inpatient hospital procedure coding; this is a variation from the WHO baseline and unique to the United States.

ICD-10-CM will replace the current code sets, ICD-9-CM, Volumes 1 and 2 for diagnosis coding, and ICD-10-PCS will replace ICD-9-CM, Volume 3 for inpatient hospital procedure coding.

What is ICD-10-PCS?

ICD-10-PCS is the Health Insurance Portability and Accountability Act of 1996 (HIPAA) standard code set that will replace Volume 3 of ICD-9-CM for inpatient facility services (services billed on a UB-04 claim form). ICD-10-PCS identifies these services by emphasizing the allocation of hospital services instead of focusing on the physician services. Current procedural terminology (CPT) will continue to be HIPAA standard code set for filing either inpatient or outpatient claims for physician services (services billed on a CMS-1500 form). Note that CPT codes should continue to be filed with procedure code modifiers as appropriate.

Why are we adopting ICD-10?

On January 16, 2009, the U.S. Department of Health and Human Services (HHS) released two final rules under HIPAA. One of these rules requires all HIPAA covered entities to adopt ICD-10-CM for diagnosis coding and ICD-10-PCS for inpatient hospital procedure coding. 

Reasons for requiring these changes include:

  • The current ICD-9 code set is running out of diagnosis and procedure codes. As a result, the codes will not be able to continue to keep pace with new treatments and technologies that are developed or new diagnoses that are defined. In the long term, this will lead to poor or incomplete data regarding the use of new technology and patient outcomes.
  • The new ICD-10 codes contain significantly greater clinical detail which will aid in a range of quality related programs. Hundreds of new diagnosis codes are submitted by medical societies, quality monitoring organizations and other organizations annually. ICD-10 will allow not only for more codes but also for greater specificity and thus better epidemiological tracking.
  • The remainder of the industrialized world has adopted ICD-10, and as diseases cross borders, we will be able to better track and react to global risks

What are the benefits of ICD-10?

There are a number of benefits to implementing the ICD-10 code set. These include:

  • Improving the accuracy of claims processing
  • More accurate and detailed clinical reporting
  • Better tracking of patient outcomes
  • Fine tuning quality programs

What does ICD-10 compliance mean?

ICD-10 compliance means that all HIPAA covered entities are able to successfully document clinical events and process health care transactions and analytics on or after the compliance date 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.
In 2014, the U.S. Department of Health and Human Services issued a rule finalizing October 1, 2015, as the compliance date for health care providers, health plans and health care clearinghouses to transition to ICD-10.

Who must comply with ICD-10?

All HIPAA covered entities including health plans, health care clearinghouses, and certain health care providers must transition to ICD-10. Although, in some instances non-covered entities may not be required to adopt ICD-10, it might be beneficial for them to do so to continue doing business with health professionals that do convert to ICD-10.

Will state Medicaid programs be required to transition to ICD-10?

Yes. Like all other HIPAA covered entities, state Medicaid programs must comply with the
ICD-10 requirements. We understand Centers for Medicare & Medicaid Services (CMS) is working with Medicaid programs to help ensure they can meet the deadline.

Are any other countries currently using ICD-10?

Yes, most other countries are already using a version of ICD-10. The United States is the last industrialized nation to adopt ICD-10. It is important to understand that the ICD-10 CM and PCS codes for the U.S. represent a variation from the baseline established by the WHO. This variation was developed as part of standard code maintenance activities led by Federal Agencies including CMS and the CDC; because of this variation and the use of the codes for reimbursement in the U.S., the insights from other countries may be limited.

What are the differences between ICD-9 and ICD-10?

In some ways, ICD-10 is similar to ICD-9. The guidelines, conventions, rules and organization of the codes are very similar. The big differences between the two systems are differences that will affect information technology and software. Specifically:

  • ICD-10-CM codes range in length from three to seven digits instead of the three to five digits in ICD-9-CM.
  • ICD-10-PCS codes are formatted as seven alphanumeric digits instead of the three or four numeric digits used under ICD-9-CM procedure coding.
  • Coding using ICD-10-PCS is much more specific and substantially different from ICD-9-CM procedure coding.

What are the differences between ICD-9 and ICD-10?

 In some ways, ICD-10 is similar to ICD-9. The guidelines, conventions, rules and organization of the codes are very similar. The big differences between the two systems are differences that will affect information technology and software. Specifically:

  • ICD-10-CM codes range in length from 3 to 7 digits instead of the 3 to 5 digits in ICD-9-CM.
  • ICD-10-PCS codes are formatted as 7 alphanumeric digits instead of the 3 or 4 numeric digits used under ICD-9-CM procedure coding.
  • Coding using ICD-10-PCS is much more specific and substantially different from ICD-9-CM procedure coding.

The following table compares the features of the ICD-9 and ICD-10 diagnosis code sets:

 Diagnosis Code Comparison

ICD-9-CM (Volume 1&2)   

ICD-10-CM

 3-5 characters in length

 3-7 characters in length

 First digit may be alpha (E or V) or numeric; digits 2-5 are numeric

 Digit 1 is alpha (to indicate the category);
Digit 2 is numeric (in the future, alpha characters may be used if code expansion is needed);
Digits 3-7 can be alpha or numeric

 Limited space for adding new codes

 Flexible for adding new codes

 Lacks detail

 Very specific

 Lacks laterality

 Includes laterality (i.e., codes identifying right vs. left)

 The following table compares the features of the ICD-9 and ICD-10 procedure code sets:

 Inpatient Hospital Procedure Code Comparison 
 

ICD-9-CM (Volume 3)

 ICD-10-PCS

3-4 numbers in length

7 alpha-numeric characters in length

Approximately 4,000 codes

Approximately 72,000 available codes

Based on outdated technology

Reflects current usage of medical terminology and devices

Limited space for adding new codes

Flexible for adding new codes

Lacks detail

Very specific

Lacks laterality

Includes laterality (i.e., codes identifying left vs. right)

Generic terms for anatomic sites

Detailed description of anatomic site

Lacks descriptions of methodology and approach for procedures

Provides detailed descriptions of methodology and approach for procedures.

Lacks precision to adequately define procedures

Precisely defines procedures with detail regarding anatomic site, approach, device(s) used and qualifying information.

What should physicians, health care professionals and institutions do to prepare for ICD-10?

  • Educate yourself and your staff about the ICD-10 compliance requirements.
  • Review communications, training materials and tools available on governmental and professional organization websites.
  • Contact your clearinghouse and ask them to provide their recommended steps to becoming ICD-10 compliant.
  • Ask your vendors for their plan to convert to an ICD-10 compliant version. Note: There may be a cost associated with upgrading your software.
  • Please note: We do not support attempts to transform ICD-9 based records into ICD-10 records by merely cross-walking them. This may create artificial variation that may impact reimbursement and reporting.

Where can providers find training opportunities?

ICD-10 resources are available through CMS, Medicare administrative contractors (MACs), professional associations and societies such as the American Health Information Management Association (AHIMA) and the American Academy of Professional Coders (American Academy of Professional Coders), and practice management system/EHR vendors.

To learn more, visit the resources below:

Will BlueChoice HealthPlan Medicaid be ready to accept ICD-10 codes on the October 1, 2015, compliance date?

Yes. We are accepting and processing ICD-10 codes on the October 1, 2015, compliance date.

We will not accept ICD-9 codes for claims with dates of service (DOS)/discharge (DOD) on or after the October 1, 2015, compliance date. ICD-9 claims processing will not change due to the transition to ICD-10, but rather will be processed based on the DOS/DOD.

Claims with both ICD-9 codes and ICD-10 codes, or mixed claims, will not be accepted. Such claims will need to be separated and filed with the correct code set for the DOS/DOD.

When resubmitting claims, use the code set valid for the DOS/DOD.

Is BlueChoice HealthPlan Medicaid accepting pre-authorization requests using ICD-10 diagnosis and procedure codes?

Yes, we are accepting and processing pre-authorization requests containing ICD-10 codes for services scheduled on or after the October 1, 2015, compliance date. ICD-9 codes must be used to pre-authorize services scheduled before the compliance date. For pre-authorizations that span the compliance date, the code set for the preauthorization will vary depending on the scenario.

See chart below.

Type of Service Begins Ends Pre-authorization Claim

 Inpatient

Admission begins on or after the 10/1/2015 compliance date

Discharge on or after the 10/1/2015 compliance date

Pre-authorization must be requested with ICD-10 codes

Claim for services rendered on or after the 10/1/2015 compliance date must be billed with ICD-10 codes

 Inpatient with unknown discharge date

Admission begins before the 10/1/2015 compliance date

Unknown at the time of admission, then discharge occurs on or after the 10/1/2015 compliance date

Pre-authorization must be requested with ICD-9 codes. This pre-authorization will be valid for the entire admission

The code set used on the claim will be based on the discharge date, so the entire claim must be billed with ICD-10 codes

 Inpatient with known discharge date

Admission begins before the 10/1/2015 compliance date

Known discharge on or after the 10/1/2015 compliance date

Pre-authorization should be requested with ICD-10 codes

The code set used on the claim will be based on the discharge date, so the entire claim must be billed with ICD-10 codes

Outpatient services

Service on or after the 10/1/2015 compliance date

NA

Pre-authorization should be requested with ICD-10 codes

Claim must be filed with ICD-10 codes

Long-term outpatient services (i.e., physical therapy, radiation therapy, chemotherapy, etc.)

Services begin before the 10/1/2015 compliance date

Services end on or after compliance date

Pre-authorization obtained in ICD-9 will be valid for services rendered on or after the 10/1/2015 compliance date

The claims for these services need to be split and filed with the correct code set for the date(s) of service. Claims with both codes sets, or mixed claims, will not be accepted

Will claims with ICD-10 code process correctly if the pre-authorization is submitted with ICD-9 code?

Yes.

Will claims with ICD-10 codes be accepted prior to the October 1, 2015 compliance date?

No, we will not accept ICD-10 codes prior to the October 1, 2015, compliance date.

Will BlueChoice HealthPlan Medicaid be ready to send ICD-10 codes on your outbound extracts and reports?

Yes. We have updated our current outbound extracts and reports to accommodate and include ICD-10 codes.

Will BlueChoice HealthPlan Medicaid be dual processing in relation to ICD-10 transition?

No. In alignment with CMS guidelines, we will not dual process. We will not accept ICD-9 codes on claims with DOS/DOD on or after the October 1, 2015, compliance date. 

Have your medical necessity criteria or medical policies been updated with ICD-10 codes? What is your translation process?

Yes. Our medical policies and clinical utilization management (UM) guidelines have been updated with ICD-10 coding and we continue to update these on a quarterly basis. We have conducted extensive testing of related system edits to help ensure consistency with the original intent of the policies and guidelines.

ICD-9 procedures and diagnoses were recoded with ICD-10 diagnosis and procedure codes using ICD-10 coding books and indexes to select the correct codes based on the positions in the policies and guidelines.

Our policies and guidelines are available on our provider website. The ICD-10 coding is included within the coding section.

For services that span the October 1, 2015, compliance date, does BlueChoice HealthPlan Medicaid have guidelines for which code set to use in filing claims?

For services that span the October 1, 2015, compliance date, use the chart below to determine which code set to use to bill the claim(s).

For claims where it is noted in the chart below that the claim must be split, the claim will be rejected by our Electronic Data Interchange (EDI) processes if it is not split.

Note that guidance may differ from CMS guidance on certain claim types where indicated.

Institutional providers

 

Bill type(s)

Facility type/services

Claims processing requirement

From or through date

 11X

Inpatient hospitals

If the hospital claim has a discharge and/or through date on or after 10/1/2015, then the entire claim is billed using ICD-10.

 Through

 12X

Inpatient Part B hospital services

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015.

 From

 13X

Outpatient hospital

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015.

 From

 14X

Non-patient laboratory services

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015.

 From

 18X

Swing beds

If the Swing bed/SNF claim has a discharge and/or through date on or after 10/1/2015, then the entire claim is billed using ICD-10.

Through

 21X

Skilled nursing – inpatient Part A

If the Swing bed/SNF claim has a discharge and/or through date on or after 10/1/2015, then the entire claim is billed using ICD-10.

Through

 22X

Skilled nursing facilities – inpatient Part B

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015.

From

 23X

Skilled nursing facilities – outpatient

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015.

From

 28X

Skilled nursing swing bed If the Swing bed/SNF claim has a discharge and/or through date on or after 10/1/2015, then the entire claim is billed using ICD-10. Through

 32X

Home health – inpatient Part B

Allow HHAs to use the payment group code derived from ICD-9 codes on claims which span 10/1/2015, but require those claims to be submitted using ICD-10 codes.

Through

 34X

Home health – outpatient

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015.

From

 41X

Religious non-medical health care institution –inpatient

If the hospital claim has a discharge and/or through date on or after 10/1/2015, then the entire claim is billed using ICD-10.

Through

 43X

Religious non-medical health care institution – outpatient services

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015.

From

 65X

Intermediate care – level I

If the hospital claim has a discharge and/or through date on or after 10/1/2015, then the entire claim is billed using ICD-10.

Through

 66X

Intermediate care – level II

If the hospital claim has a discharge and/or through date on or after 10/1/2015, then the entire claim is billed using ICD-10.

Through

 71X

Rural health clinics

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015.

From

 72X

End stage renal disease (ESRD)

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015.

From

 73X

Free standing clinic

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015.

From

 74X

Outpatient therapy

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015.

From

 75X

Comprehensive outpatient rehab facilities

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015.

From

 76X

Community mental health clinics

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015.

From

 77X

Federally qualified health clinics

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015.

From

 78X

Licensed free standing emergency medical facility

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015.

From

 79X

Clinic – other

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015.

From

 81X

Hospice – hospital

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015.

From

 82X

Hospice – nonhospital

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015.

From

 83X

Specialty facility ambulatory surgery

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015.

From

 84X

Freestanding birthing center If the hospital claim has a discharge and/or through date on or after 10/1/2015, then the entire claim is billed using ICD-10. Through

 85X

Critical access hospital

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015.

From

 86X

Residential facility

If the hospital claim has a discharge and/or through date on or after 10/1/2015, then the entire claim is billed using ICD-10.

Through 

 89X

Special facility other

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015

Through

Other claim types

Type of claim

Claims processing requirement

From or through date

Long-term outpatient services (such as physical therapy, radiation therapy, chemotherapy, etc.)

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015.

From

All anesthesia claims

Anesthesia procedures that begin on 9/30/2015 but end on 10/1/2015 are to be billed with ICD-9 diagnosis codes and use 9/30/2015 as both the FROM and THROUGH date. EDI will reject the claim to split if the claim is submitted as a span claim.

From

Durable medical equipment (DME) POS (this may differ from Medicare filing guidance)

Split the claim so all ICD-9 codes are on one claim with DOS through 9/30/2015 and all ICD-10 codes are on the other claim with DOS on/after 10/1/2015.

Through

What is your response to the “July 6, 2015 CMS/AMA Announcement and Guidance regarding ICD-10 Flexibilities?"

On July 6, 2015, CMS and the American Medical Association (AMA) announced guidance that will allow for flexibility in the claims auditing and quality reporting process for 12 months after ICD-10 implementation as the medical community gains experience using the new ICD-10 code set.

We will adhere to the CMS/AMA Medicare Part B announcement released on July 6, 2015. The CMS announcement applies ONLY to Medicare Part B Fee-For-Service provider claims. Specifically, we will not reject Medicare Part B fee-for-service claims that are coded with an ICD-10 within the correct family even if the correct level of specificity was not used. However, all claims including Medicare Part B with a date(s) of service/date(s) of discharge on or after the compliance date must have valid ICD-10 codes. We will still reject incorrectly coded ICD-10 claims for Medicare Part B.

In general, ICD-10 coding specificity will come into play primarily with application of our medical policy and member benefit application. In most cases, use of a valid ICD-10 code from a “family of codes” (e.g., the ICD-10 three character category) will enable claims processing without denial. Note that there may be some situations, particularly with our medical policy, where the specificity of the clinical criteria will demand the maximum level of ICD-10 code specificity.

For our detailed response, please visit the ICD-10 webpage on our provider home website. More information on this guidance and the related Frequently Asked Questions (FAQs) are also available on the CMS website at http://www.cms.gov/icd10.

Once ICD-10 is implemented, will the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) codes be allowed on behavioral health claims to report diagnoses?

No. Consistent with current claims filing standards, DSM-5 codes are not allowed to report diagnoses for services on claims. All claims with DOS/ DOD on or after the October 1, 2015, compliance date will need to be submitted with their associated ICD-10-CM codes.
More information on the DSM-5 and their associated ICD-10-CM codes (identified by the American Psychiatric Association) can be found at http://www.dsm5.org.

Will BlueChoice HealthPlan Medicaid EDI edits change as a result of the implementation of ICD-10?

Yes. We have implemented specific edits for electronic claims to ensure the appropriate use of ICD-9 versus ICD-10 code sets as of the compliance date. Implementation of these new edits does not affect the way existing claim edits are applied today.

New institutional, professional and dental claims edits and eligibility edits were implemented at the EDI Gateway. Our EDI Gateway will reject any claim that is not ICD-10 compliant and the errors will be reported back to the claim submitter through the existing EDI reports or letters. EDI rejected claims will not be processed further through our systems.

Notifications about these edits and respective messages were sent to all our EDI trading partners 90 days in advance of the compliance date. This information is also available in the Latest News section on our E-Solutions EDI webpage.

Will BlueChoice HealthPlan Medicaid’s paper claim edits change as a result of the implementation of ICD-10?

Yes. We have implemented specific edits for paper claims to ensure the appropriate use of ICD-9 versus ICD-10 code sets as of the compliance date. Implementation of these new edits does not affect the way existing claim edits are applied today.

We will reject any claim that is not ICD-10 compliant and the errors will be reported back to the claim submitter through the existing reports or letters.

What version of CMS-1500 claim form will BlueChoice HealthPlan Medicaid be accepting for ICD-10 implementation?

Paper claims must be submitted using the new ICD-10 compliant CMS-1500 form (02-12) version as of the compliance date. We will no longer accept previous versions of the CMS-1500 claim form for paper claims, including CMS-1500 form (08-05) version. Also note that ICD-10 codes can only be filed on the CMS-1500 claim form (02-12) version. For more guidance on the new version, see the National Uniform Claim Committee (NUCC) website at www.nucc.org.

What version of diagnosis related group (DRG) grouper will BlueChoice HealthPlan Medicaid be using for ICD-10 implementation?

Most of our claims will be processed using v32 test version until v33 is installed. Refer to your contract language for our standard DRG grouper upgrade processes, as applicable.

Will reimbursement methodology be impacted by ICD-10?

We do not anticipate material impact to provider reimbursement due to the implementation of ICD-10. Consistent with findings throughout our industry, our ongoing internal analysis and testing, we anticipate there will be changes in DRGs due to ICD-10. Though we do not anticipate these changes will have material impact to reimbursement, we cannot guarantee the reimbursement impact to our providers.

Will your physician performance measurement programs for quality and efficiency be impacted by ICD-10?

Our physician performance measurement programs leverage our data warehouse, which has been remediated for ICD-10 since 2013 and is ICD-10 compliant. We have also remediated provider facing reports, dashboards and scorecards that are code based. We’ve also performed end-to-end testing to help ensure that our population health reports associated with our programs are accurate, and we anticipate no ICD-10 related issues in this area.

In addition, in applicable markets, our Enhanced Personal Health Care (EPHC) program’s risk-adjusted incentive payment algorithms will employ a modified measuring, monitoring and adjustment strategy. If significant ICD-10 induced changes in medical risk scores are confirmed, then we will consider a revision to the normalization methodology for the EPHC risk-adjusted incentive payment algorithms to neutralize the impact of ICD-10 on our incentive program.

Are there any guidelines to assist providers with the ICD-10 claims coding?

We suggest providers use CMS general equivalence mappings (GEMs) as a guideline for ICD-10 coding. The GEMs documents (user guides and summary documents) are available on the CMS website at http://www.cms.gov/icd10. Note that there are several other coding resources available in the industry. Check with your professional associations for other resources.

Does BlueChoice HealthPlan Medicaid use the CMS GEMs for ICD-10-CM and ICD-10-PCS to remediate your systems?

We referenced the CMS GEMs in our ICD-10 remediation process, though we have not solely relied on them in coding our systems. Our systems are configured to natively adjudicate claims with ICD-10 codes directly and do not use GEMs crosswalks for claims processing. We will not map any ICD-10 codes on claims back to ICD-9 codes nor will there be any connection between ICD-9 codes and ICD-10 codes during claims adjudication.

ICD-10 testing

What types of testing has BlueChoice HealthPlan Medicaid conducted to help ensure that all of its systems and processes will be ready for ICD-10?

We have completed all system development and implementation, business configuration and content type changes, as well as external and internal testing. Our efforts over the last several years and our approach to discovering, understanding and predicting the impact of ICD-10 codes included extensive end-to-end testing with over a dozen EDI claims clearinghouses and a multitude of provider organizations, individual hospitals and physician groups. We believe that the extensive internal and external testing that we have conducted has demonstrated our systems' ability to receive and process claims with ICD-10 codes.

Through this testing, we have verified:

  • Claims files are correctly processed in our EDI Gateway.
  • Claims are correctly processed through the transaction flow of our adjudication systems.
  • Claims are correctly coded for ICD-10.
  • Claims are correctly processed for expected business outcomes.

In addition, we also offered all EDI direct submitters to test with us using TIBCO Validator®, a self-guided, web-based processing tool that offers unlimited testing of file formats and edits utilizing ICD-10 codes. This tool is available until September 30, 2015.

ICD-10 issues resolution processes

What is BlueChoice HealthPlan Medicaid’s contingency plan in the event claims processing is delayed?

In the event that a claims system cannot process claims, our strategy is to manually process them according to the procedures already in place for such events. We have also evaluated and implemented contingency staffing to support this effort.

If a provider experiences delays in claims processing, we recommend that the provider follow existing claim inquiry processes and initially contact the Provider Service Call Center for the locality and line of business involved. Please visit our provider home webpage for contact information.

Is BlueChoice HealthPlan Medicaid making advance payments to providers in the event of ICD-10 claim filing or processing issues?

No.

What should providers do if their claims are impacted by ICD-10 issues?

Our strategy in the event that claims processing is impacted by ICD-10 is to follow the procedures already in place for such events. Information on the existing processes is available on our provider home webpage. We do not have a dedicated ICD-10 call center.

In the event that a provider experiences a rejected claim submission due to diagnosis code, the rejection would be due to an invalid code. If a provider experiences a claim denial with reason codes indicative of diagnosis code issue the provider cannot resolve, we recommend that the physician follow existing claim inquiry processes. Initial contact with us for such issue should be with the Provider Service Call Center for the locality and line of business involved.

In the event that a provider experiences an unusually high volume of denials, we recommend escalation to the provider’s local Provider Solutions representative for a more comprehensive review and analysis of such denials. The facts and circumstances of each such scenario will be individually evaluated, and consideration of any accommodation will take into account such facts and circumstances.

What if I receive an overpayment due to the splitting of services into ICD-9 and ICD-10 separate claims when services span the ICD-10 compliance date?

Some provider reimbursement agreements limit the reimbursement amounts for certain outpatient services, such as when combined services are negotiated as a case rate. Outpatient services that span the compliance date will need to be separated and filed with the correct code set for the DOS/DOD. Splitting the claim could cause these episodes of care to be overpaid.

In the event that a physician receives an overpayment, please notify us immediately and refund the overpaid amount back to us. When we request a refund of any overpayment amounts discovered, we expect you to remit refunds promptly once notified.

Will BlueChoice HealthPlan Medicaid monitor and share information related to ICD-10 claim submission trends and processing?

We have developed tracking and reporting mechanisms to monitor aspects of our business susceptible to ICD-10 transition. The data from the monitoring will be used to address changes to existing processes and conduct one-on-one outreach with our partners, as necessary. The information is considered proprietary and will not be available for external access. We currently do not have any plans to add new reporting related to ICD-10 for external distribution. Regular provider reports that are currently shared have been updated to reflect ICD-10 data.

What is the issue resolution process for providers after ICD-10 implementation?

The process for providers to resolve and escalate issues will not change for any ICD-10 implementation issues. We recommend that the provider initially contact the Provider Service Call Center for the locality and line of business involved. Please visit our provider home webpage for the contact information or call the number listed on the member ID card.

What is the issue resolution process for EDI trading partners after ICD-10 implementation?

The process for EDI trading partners to resolve and escalate issues will not change. Clearinghouses should continue to use the existing channels in place today, starting with contacting their local E-Solutions Support team as listed on our EDI E-Solutions home webpage.

What is the issue resolution process for members after ICD-10 implementation?

The process for members to resolve and escalate issues will not change. Members should continue to use the existing channels in place today, starting with contacting the customer service, either by calling the number listed on the member ID card or by using the contact information listed on our member home webpage.

ICD-10 training and resources

What type of ICD-10 training has BlueChoice HealthPlan Medicaid conducted for its staff?

Our customer service unit, e-Solutions support team, and call centers have been trained and are well prepared to support ICD-10 related inquiries. We have provided training to our provider call units to address questions related to ICD-10 and have rolled out ICD-10 fundamental, coding and system specific courses to our clinical staff, operations area, sales associates and others.

What type of outreach is BlueChoice HealthPlan Medicaid doing with providers and external partners to assist with ICD-10 compliance readiness?

We have been very active in the industry and have continued communication and education to our provider community by engaging in provider education, training and awareness regarding issues related to using ICD-10 codes.
We have established several tools such as a dedicated ICD-10 webpage in the provider portal website; announcements and ongoing updates in the newsletters, bulletins and e-blasts; and frequently asked questions. We have also conducted surveys with the selected vendors, providers and trading partners to assess their ICD-10 readiness status.