ICD10 Frequently Asked Questions

October 19th, 2015
Frequently Asked Questions
Q: What is ICD-10-CM and ICD-10-PCS?
A:  ICD-10-CM (International Classification of Diseases -10th Revision-Clinical Modification) is a US clinical modification of the WHO’s ICD-10, developed to support US health information needs. ICD-10-CM is designed for classifying and reporting diseases in all US healthcare settings. ICD-10-PCS (Procedure Classification System) was developed by CMS and is not based on an international coding system. ICD-10-PCS replaces the ICD-9-CM procedure coding system and will only be required for facilities reporting procedures on hospital inpatient services. When speaking of both these new classifications, the term “ICD-10″ is often used.
Q: Who has to comply with ICD-10?
A: ICD-10 will affect diagnosis and inpatient procedure coding for everyone covered by the Health Insurance Portability and Accountability Act (HIPAA), not just those who submit Medicare or Medicaid claims.
Q: Why is it important not to further delay the implementation of ICD-10?
A: ICD-10-CM and ICD-10-PCS must be adopted as soon as possible to reverse the trend of deteriorating health data. Never in US history have we used the same version of ICD for 35 years. In addition, many countries have already moved to ICD-10.
Q: Will ICD-10-PCS procedure codes be used for both inpatient and outpatient hospital services?
A: No. ICD-10-PCS procedure codes are designed only for hospital reporting of inpatient services. Current Procedural Terminology (CPT) codes will continue to be used for physician and outpatient services.
Q: ICD-10 seems so complicated. Do physicians really need to use all the codes in ICD-10?
A: No. Healthcare providers will not use all the codes in the classification system; rather they will use a subset of codes based on their practice. Physicians will only use the ICD-10-CM code set for diagnosis coding. The ICD-10-CM code set is like a dictionary that has thousands of words, but individuals use some words very commonly while other words are never used.
Q: Does ICD-10 compete with other healthcare initiatives that require time and resources to implement?
A: Healthcare organizations and providers have known for 14 years that ICD-10 implementation would occur and that they should prepare for the implementation, and the industry began to officially move toward implementation in 2008. While there are always competing priorities, the US healthcare system has already waited too long to realize the benefits of ICD-10. In addition, many healthcare initiatives are tied to ICD-10 implementation, so they work hand in hand.
Q: What are the benefits of ICD-10?
A: ICD-10 will improve national healthcare initiatives such as Meaningful Use, value-based purchasing, payment reform and quality reporting. Without ICD-10 data, there will be serious gaps in the ability to extract important patient health information needed to support research and public health reporting, and move to a payment system based on quality and outcomes.
Q: What is the value of ICD-10?
A: The improved clinical detail, better capture of medical technology, up-to-date terminology, and more flexible structure will result in:
  • Higher quality information for measuring healthcare service quality, safety, and efficiency
  • Greater coding accuracy and specificity
  • Recognition of advances in clinical practice and technology
  • Improved ability to measure outcomes, efficacy, and costs of new medical technology
  • Enhanced review of medical necessity and fewer claims denials
  • Improved ability to determine disease severity for risk and severity adjustment
  • Global healthcare data comparability
  • Improved ability to track and respond to public health threats
  • Reduced need for manual review of health records to perform research and data mining and adjudicate reimbursement claims
  • Reduced need for supporting documentations to support information reported on claims
  • Reduced opportunities for fraud and improved fraud detection capabilities
  • Development of expanded computer-assisted coding technologies that will facilitate more accurate and efficient coding and alleviate the coder shortage
  • Space to accommodate future code expansion
Q: What will happen if I submit a claim with a DATE OF SERVICE of Oct. 1, 2015 and later with an ICD-9 code?
A: All claims that are received with a DATE OF SERVICE of Oct. 1, 2015 and later with an ICD-9 code will be denied.
Q: What should I do if my claim is rejected? Will I know whether it was rejected because it is not a valid code versus denied due to a lack of specificity required for a National Coverage Determination (NCD) or Local Coverage Determination (LCD) or other claim edit?
A: Yes, submitters will know that it was rejected because it was not a valid code versus a denial for lack of specificity required for a NCD or LCD or other claim edit. Submitters should follow existing procedures for correcting and resubmitting rejected claims and issues related to denied claims.
Q: What are the “established time limits” to process claims?
A: Guam Public Law 25-189, Section § 9902. Prompt Payment for Health Care and Health Insurance Benefits, “(b) Health Plan Administrators shall reimburse a Clean Claim, or any portion thereof, submitted by a patient or Health Care Provider that is eligible for payment and not contested or denied not more than 45 calendar days after receiving the Clean Claim filed in writing.”
Q: How will the transition from ICD-9 to ICD-10 work with Referral/Authorization transactions and subsequent episode of care?
A . Authorization requests will require the provider to supply the diagnosis using the correct ICD format depending on the requested start date. For requested dates of service or date of admission prior to October 1, 2015, the ICD-9 codes will be utilized.
For requested dates of service or date of admission start from October 1, 2015 and beyond, the appropriate ICD-10 codes will be utilized.
Q: If providers have questions about the testing, who can they contact?
A. For questions related to ICD-10 testing, providers can call the EDI Help Desk at 649-6956, extension 7229 or via email to editeam@takecareasia.com
Q: Specify whether you system can accommodate both ICD-10-CM/PCS and ICD-9-CM code sets in dual testing strategy?
A. During the testing phase, providers will be able to submit claims with both ICD-9 and ICD-10 codes to test dual use in the TakeCare testing environment.