• Q: When was the deadline for transitioning to ICD 10?

    October 1, 2015 was the deadline for the transition to ICD 10.

  • Q: Who was affected by the transition to ICD-10?

    Everyone covered by HIPAA must transition to ICD-10. This includes providers and payers who do not deal with Medicare claims.

  • Q: What does ICD-10 compliance mean?

    ICD-10 compliance means that everyone covered by HIPAA is able to successfully conduct health care transactions using ICD-10 codes.

  • Q: What should providers do to prepare for the transition to ICD-10?

    Providers should plan to test their ICD-10 systems early, to help ensure compliance. Beginning steps in the testing phase include:

    • Internal testing of ICD-10 systems
    • Coordination with payers to assess readiness
    • Project plan launch by data management and IT teams

    For providers who have not yet started to transition to ICD-10, below are actions steps to take now:

    • Develop an implementation plan and communicate the new system changes to your organization, your business plan, and ensure that leadership and staff understand the extent of the effort the ICD-10 transition requires.
    • Secure a budget that accounts for software upgrades/software license costs, hardware procurement, staff training costs, work flow changes during and after implementation, and contingency planning.
    • Talk with your payers, billing and IT staff, and vendors to confirm their readiness status.
    • Coordinate your ICD-10 transition plans among your partners and evaluate contracts with payers and vendors for policy revisions, testing timelines, and costs related to the ICD-10 transition.
    • Create and maintain a timeline that identifies tasks to be completed and crucial milestones/relationships, task owners, resources needed, and estimated start and end dates.

  • Q: What should payers do to prepare for the transition to ICD-10?

    The transition to ICD-10 will involve new coding rules, so it will be important for payers to review payment policies. Payers should ask software vendors about their readiness plans and timelines for product development, testing, availability, and training. The ICD-10 Implementation Handbook for payers on the cms website provides detailed information for planning and executing the transition.

More FAQs - Clarifying Questions & Answers

  • Q: Does the Guidance mean there is a delay in ICD-10 implementation?

    No. The CMS/AMA Guidance does not mean there is a delay in the implementation of the ICD-10 code set requirement for Medicare or any other organization. Medicare claims with a date of service on or after October 1, 2015, will be rejected if they do not contain a valid ICD-10 code. The Medicare claims processing systems do not have the capability to accept ICD-9 codes for dates of service after September 30, 2015, or accept claims that contain both ICD-9 and ICD-10 codes for any dates of service. Submitters should follow existing procedures for correcting and resubmitting rejected claims.

  • Q: What is a valid ICD-10 code?

    All claims with dates of service of October 1, 2015 or later must be submitted with a valid ICD-10 code; ICD-9 codes will no longer be accepted for these dates of service. ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity. A 3-character code is to be used only if it is not further subdivided. While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, if a valid ICD-10 code from the right family (see question 5) is submitted, Medicare will process and not audit valid ICD-10 codes unless such codes fall into the circumstances as described below.

  • Q: Is the decimal point of an ICD-10-CM code required?

    No. The ICD codes do have a decimal and ICD-10 diagnosis codes are usually displayed with a decimal point between the 3rd & 4th character of the code, however, for transaction and/or submission of the codes, the decimal should NOT be included. The reporting of the decimal is unnecessary because it is implied, and may be rejected if included in your submission. Preciseness of the code is designated with the number digits to the right of the “implied” decimal point.

  • Q: Does the recent Guidance mean that no claims will be denied if they are submitted with an ICD-10 code that is not at the maximum level of specificity?

    In certain circumstances, a claim may be denied because the ICD-10 code is not consistent with an applicable policy, such as Local Coverage Determinations or National Coverage Determinations. (See below for more information about this). This reflects the fact that current automated claims processing edits are not being modified as a result of the guidance.

    In addition, the ICD-10 code on a claim must be a valid ICD-10 code. If the submitted code is not recognized as a valid code, the claim will be rejected. The physician can resubmit the claims with a valid code.

  • Q: National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) often indicate specific diagnosis codes are required. Does the recent Guidance mean the published NCDs and LCDs will be changed to include families of codes rather than specific codes?

    No. As stated in the CMS' Guidance, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family of codes. The Medicare review contractors include the Medicare Administrative Contractors, the Recovery Auditors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor.

    As such, the recent Guidance does not change the coding specificity required by the NCDs and LCDs. Coverage policies that currently require a specific diagnosis under ICD-9 will continue to require a specific diagnosis under ICD-10. It is important to note that these policies will require no greater specificity in ICD-10 than was required in ICD-9, with the exception of laterality, which does not exist in ICD-9. LCDs and NCDs that contain ICD-10 codes for right side, left side, or bilateral do not allow for unspecified side. The NCDs and LCDs are publicly available and can be found at http://www.cms.gov/medicare-coverage-database/.

  • 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 NCD or LCD or other claim edit?

    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: Do the ICD-10 audit and quality program flexibilities extend to Medicare fee-for-service prior authorization requests?

    No, the audit and quality program flexibilities only pertain to post payment reviews. ICD-10 codes with the correct level of specificity will be required for prepayment reviews and prior authorization requests.