-
What is ICD-10?
ICD-10 is the International Classification of Diseases, version 10. ICD is the international standard for diagnostic classifications. The current version, ICD-9, was adopted in 1979.
-
What does ICD-10 compliance mean?
All HIPAA-covered entities 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, 2014 implementation date.
-
What is the primary purpose of this change?
The primary purpose of the change to ICD-10 is to improve clinical communication. It allows for the capture of data about signs, symptoms, risk factors and comorbidities and better describes the clinical issues overall. It will also enable the United States to exchange information across country borders.
-
What changes are occurring in the ICD-10 version?
The changes will impact ICD-9-CM diagnosis codes and ICD-9-CM procedure codes. The diagnosis codes for ICD-9 are currently three to five digits that are alphanumeric in nature and combine to make around 14,000 unique diagnosis codes being used today. For ICD-10, the diagnosis codes will be seven digits that are alphanumeric in nature and combine to make around 68,000 unique diagnosis codes. Currently, ICD-9 procedure codes are three to four digits that are numeric in nature and combine to make about 4,000 unique procedure codes. For ICD-10-PC S (inpatient), the procedure codes will be seven digits that are alphanumeric in nature and combine to make around 72,000 unique procedure codes.
-
Why is the transition to ICD-10 happening?
The primary purpose of the change to ICD-10 is to improve clinical communication. It allows for the capture of data about signs, symptoms, risk factors and comorbidities and better describes the clinical issues overall. It will also enable the exchange of information internationally.
Another reason for the transition is ICD-9 codes' limited data about patients' medical conditions and hospital inpatient procedures. At 30 years old, ICD-9 has outdated or even obsolete terms and is not consistent with current medical practice.
-
Who is affected by the transition to ICD-10?
All entities covered by HIPAA must transition to ICD-10. This includes both Medicare and commercial lines of business.
-
What happens if I don’t switch to ICD-10?
Claims that do not contain ICD-10 diagnosis and inpatient procedure codes after the implementation date will not be processed because they will be considered non-HIPAA compliant.
-
What is Humana's plan for ICD-10 acceptance?
Humana will accept ICD-9 codes on claims with a date of service (DOS) or discharge date of September 30, 2014, or prior. Humana will accept ICD-10 codes on claims with a DOS or discharge date of October 1, 2014, or after.
-
Does Humana plan to be ready to process ICD-10 codes submitted on claims forms by
October 1, 2014?
Yes. Humana will go live with the ICD-10 codes effective October 1, 2014.
-
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. For inpatient services, ICD-10 codes are required on the date of discharge after the compliance date.
-
Will there be a period of time when both codes will be required on the same claim?
No. Per CMS guidance, ICD-9 codes will no longer be accepted on institutional, professional or supplier claims (including electronic and paper) with FROM dates of service or dates of discharge/THROUGH dates on or after October 1, 2014. A claim cannot contain both ICD-9 codes and I CD-10 codes. Institutional claims will be returned to the health care provider. Professional and supplier claims will be returned as not able to process.
-
Will Humana support dual processing of ICD-9 and ICD-10 codes?
Yes. Humana will support both ICD-9 and ICD-10 coding formats for a period of time after October 1, 2014; however, Humana will only accept correctly formatted claims, both electronic and paper, which contain ICD-10 codes for dates of service and discharge dates of October 1, 2014. Humana will accept ICD-9 codes for dates of service prior to October 1, 2014, for the entire run-out cycle (taking into account spanning dates).
-
Will Humana crosswalk incoming claims with ICD-9 codes to ICD-10?
No. Humana will process claim transactions in their “native” format and will not crosswalk ICD-9 codes to ICD-10. Claims with improper diagnosis codes (based on date of service or date of discharge) will be rejected.
-
Will Humana accept ICD-10 codes before the implementation date?
No. ICD-10 codes will not be accepted before the implementation date. Also, please note that claims for dates of services before the implementation date, but submitted after the implementation date, must use ICD-9 codes.
-
Will ICD-10 codes be required for authorization of services that occur after October 1, 2014?
Yes. ICD-10 codes will be required for dates of service after the implementation date.
-
What will the appeal process be for resubmission of ICD-9-based claims with ICD-10 codes during transition period?
The appeal and resubmission process will follow the current process.
-
What changes in payment will there be with the change to ICD-10?
There should be no change to the way a claim is paid with ICD-10 and ICD-9 codes, unless a diagnosis-related group (DRG) change has taken place or a contract has been rewritten to incorporate a change of reimbursement.
-
Will you renegotiate provider contracts to replace ICD-9 codes with ICD-10 codes?
Yes, when needed. We currently have DRG and ICD contract language in a small percentage of our contracts, and will be working with health care providers to update contracts where required. Any contract changes will follow the normal process. If your contract has specific ICD or DRG language, please contact your market representative to facilitate a contract revision.
-
Why is the transition to ICD-10 any 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 three to 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 claim-processing issues does Humana anticipate with the preparation for ICD-10?
Humana is investing in remediation of systems and processes to support the ICD-10 requirements. Humana does not foresee any issues with claims processing with the change to ICD-10, although rejection due to misuse of new codes is possible. Testing will begin early 2013 to mitigate any such issues.
-
Will there be special handling for patients who are in-house over the transition?
Yes. For claims for patients in-house over the transition date, health care providers will submit claims based on the “through” date, using published CMS recommendations.
-
How will Humana handle changes in payment with ICD-10?
There should be no change in the way a claim is paid with ICD-10 codes unless: 1) a diagnosis-related group (DRG) change has taken place or 2) there are impacts to claims edited according to the procedure/diagnosis combination.
-
Will DRG Groupers continue to be based on ICD-9 codes or will the grouper determine the DRG based upon ICD-10 codes?
CMS defines DRG codes. DRGs will be based on ICD-10 codes.
-
What is Humana’s strategy to manage risks around provider contracts with stipulations on DRG and/or ICD codes?
We currently have DRG and ICD contract language in a small percentage of our contracts, and will be working with providers to update contracts where required.
-
Will Humana be using general equivalence mappings (GEMs) as part of its process, or for creating files coming in or out?
No. Humana will process transactions in their "native" format and will not be using GEMS to crosswalk ICD-9 codes and ICD-10 codes for inbound or outbound v5010A1 transactions.
-
Is Humana working in collaboration with health care providers?
Yes. Humana is planning to conduct external end-to-end testing with a select group of early adopters during the second and third quarters of 2013. If you would like to participate in Humana’s testing, please send an email to ICD10inquiries@humana.com.
-
When will Humana begin ICD-10 testing?
Selected provider testing is scheduled to occur in the second quarter of 2013. To coordinate testing, contact Humana via email at ICD10Inquiries@humana.com.
-
How do you plan to manage capitation reconciliations?
Humana does not expect any impact to capitation; our capitation reconciliation will follow the normal process.
-
Do you intend to change medical necessity requirements because of the more specific codes that will be available?
Yes. Humana is reviewing and updating Medical Policies to incorporate new ICD-10 terminology and expanded coding.
-
Will Humana update medical review policies, coverage determinations and payment determinations?
Yes. Humana is reviewing and updating Medical Policies to incorporate new ICD-10 terminology and expanded coding.
-
Will any reporting formats change?
Yes. Any reporting formats that include ICD-9 today will be remediated to reflect the ICD-10 codes.
-
When will Humana begin testing transactions?
Humana will begin testing ICD-10 transactions in the second quarter of 2013.
-
Will there be extensions given for timely filing during the ICD-10 transition time?
No. Humana does not expect any timely filing extensions at this time.
-
Does the health plan provide regular and ongoing communication to health care providers regarding ICD-10 efforts and status?
Yes. Humana’s ICD-10 program team has a communication plan and will be developing a schedule with testing partners, trading partners, health care providers and internal departments. We will keep health care providers informed about our progress via this website and Humana’s YourPractice provider magazine.
-
What key information should health care providers keep in mind as they develop their own ICD-10 implementation plans?
Humana suggests that health care providers stay up-to-date on any changes by CMS regarding ICD-10 implementation by monitoring the CMS website as well as other resources listed below. If health care providers have questions or concerns, they may submit an email to our mailbox, ICD10Inquiries@humana.com.
