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ICD-10 FAQs

What is ICD 10?
ICD-10 stands for the International Classification of Diseases, 10th Edition. (IDC is the international standard for diagnostic classifications). The current version, ICD-9, was adopted in 1979.

What does ICD-10 compliance mean?
HIPAA-covered entity must be able to successfully conduct health care transactions using the ICD-10 diagnosis and procedure codes. ICD-9 diagnosis and procedure codes can no longer be used for services provided on or after the October 1, 2015, implementation date.

What is the primary purpose of this change?
The primary purpose of the change to ICD-10 is to improve clinical communication. ICD-10 allows for the capture of data regarding signs, symptoms, risk factors and comorbidities to better describe the clinical issue overall. It will also enable the United States to exchange information across country borders.

What changes are occurring in the ICD-10 version?
ICD-10 changes impact ICD-9-CM diagnosis codes and ICD-9-CM procedure codes.

  • The diagnosis codes for ICD-9 are currently three to five digits, which are alphanumeric in nature and combine to make the 14,000 unique diagnosis codes being used today.
  • For ICD-10, the diagnosis codes will be seven alphanumeric digits that combine to make more than 68,000 unique diagnosis codes.
  • Currently, ICD-9 procedure codes are three to four numeric digits that combine to make 4,000 unique procedure codes.
  • For ICD-10-PCS (inpatient), the procedure codes will be seven alphanumeric digits that combine to make around 72,000 unique procedure codes.

Who is affected by the transition to ICD-10?
All entities covered by HIPAA must transition to ICD-10. This includes Medicare, commercial lines of business and TRICARE. TRICARE Management Authority (TMA) has mandated  “ no waivers” for providers.

What happens if a covered entity doesn’t switch to ICD-10?
Claims that do not contain ICD-10 diagnosis and inpatient procedure codes for services provided on or after the implementation date will not process. They will be considered non-HIPAA compliant.

What is the deciding factor on when to use ICD-10 codes?
For outpatient services, ICD-10 codes are required for dates of service on or after the compliance date.  Outpatient claims spanning the compliance date are required to be split.

How will payment change with the transition to ICD-10?
There should be no change to the way a claim is paid with the ICD-10 from ICD-9 codes, unless a diagnosis related grouper (DRG) change has taken place.

Why is the transition to ICD-10 different from the annual code changes?
ICD-10 is more robust and descriptive. ICD-9 codes are numeric and have three to five digits, whereas ICD-10 codes will be alphanumeric and contain seven characters.

Will ICD-10 replace CPT coding?
No. CPT coding for outpatient procedures is not affected. ICD-10 procedure codes are for hospital inpatient procedures only.

What key information should health care providers keep in mind as they develop their own ICD-10 implementation plans?
We suggest that health care providers stay up to date on any changes from CMS regarding ICD-10 implementation via the CMS website as well as other sources listed below.

  • CMS
  • Workgroup for Electronic Data Exchange (WEDI)
  • ICD-10-CM (diagnosis) code sets
  • ICD-10-PCS ( hospital inpatient procedure) code sets
  • ICD-10-CM official guidelines for coding and reporting
  • American Health Information Management Association  (AHIMA)
  • New FAQs for Referrals/Authorizations submitted beginning January 2015 regarding ICD 10.

When will HGB accept ICD-10 diagnosis codes on referral and authorization requests?
HGB will accept ICD -10 codes as part of the referral and authorization process starting June 2015 on requests for dates of service after 10/1/2015. The online referral/authorization application on the secured provider portal at HumanaMilitary.com will be prepared to build your new requests for dates of service applying ICD 10 codes starting June 2015 - this is for those requests where the dates of service are on or after 10/01/2015.

Where else can my office view ICD 10 diagnosis codes?
HGB has recently updated the secured provider portal “Code Look-Up” feature to include ICD 10 codes and descriptors alongside the ICD 9 Code Look Up. Messaging reminding providers that the ICD 10 diagnosis codes will be required for referral/auth submissions for Dates of Service on or after 10/01/2015 has been posted to this application.  The Code Look-Up feature demonstrates referral/auth requirements by procedure and/or diagnosis code to assist the provider in determining the need to create a request for a TRICARE beneficiary

Will I need to submit new requests if the dates of service goes beyond 10/1/2015 on current referrals/authorizations?
End dates will not be adjusted on open valid referrals. Beneficiaries will not be required to obtain a new referral just because of the diagnosis coding change.

What codes should I submit on new requests?

  • An ICD-10 code should be submitted on new requests entered after 10/1/2015 with an actual or expected date on or after 10/1/2/15.
  • An ICD-10 code should be submitted on new requests entered prior to 10/1/2015 with an actual or expected date on or after 10/1/2/15.
  • Continue to enter ICD- 9 code for new requests entered on or after 10/1/2015 (retro) with an actual date of service prior to 10/1/2015.

What happens if I submit an update to a referral or authorization that was requested prior to 10/1/2015?

  • If the request was entered prior to 10/1/2015 (with ICD-9 codes) with a date of service before 10/1/2015, and an update to a diagnosis code is needed after 10/1/2015, submit an ICD-9 code.
  • If the request was entered prior to 10/1/2015 (with ICD-9 codes) with a date of service after 10/1/2015, and an update to a diagnosis code is needed after 10/1/2015, submit an ICD-10 code.

Payer Assessment Status
Humana Military and PGBA will be ready to accept ICD-10 claims for dates of service beginning October 1, 2015.

Modifications to the claims system will be complete by the end of July 2015. End to end testing has been ongoing since 2013 in preparation for implementation.

Referrals and Authorizations are done on line. There is no change.

This webpage, which will include updates, FAQs, national resource listings, and other ICD readiness information, is the public provider education forum for TRICARE South Region  and Humana Military Network Providers.

Humana Military working with PGBA will perform internal systems testing throughout 2013-2014 with plans to be ready to implement several months prior to October 1, 2015.  PGBA does not plan to outreach to independent providers/groups for testing, but will survey clearinghouses and select providers during that timeframe, to ensure provider readiness.

(Other assessment Q&A will be added as the information becomes available)