On October 1, 2014, the United States health care industry will transition from the International Classification of Diseases, 9th Edition (ICD-9), to the International Classification of Diseases, 10th Edition (ICD-10), for medical diagnosis and inpatient procedure coding. ICD-10 diagnosis codes must be used for all health care services provided in the U.S. ICD-10 procedure codes must be used for all hospital inpatient procedures. Claims with ICD-9 codes for services provided on or after the compliance deadline cannot be processed.
ICD-10 will affect diagnosis and inpatient procedure coding for everyone covered by the Health Insurance Portability and Accessibility Act (HIPAA). Health care providers, payers, clearinghouses and billing services must be prepared to comply with the transition to ICD-10. All electronic transactions must use Version 5010 standards, which have been required since January 1, 2012. Unlike the older Version 4010/4010A standards, Version 5010 accommodates ICD-10 codes. Humana became fully Version 5010 compliant on January 1, 2012. Humana is scheduled to be fully functional and compliant with the ICD-10 implementation deadline as well.
Health care providers are encouraged to look for specialty-specific ICD-10 training offered by societies and professional organizations. ICD-10 coding training will be integrated into the continuing education units (CEUs) that certified coders must take to maintain their credentials. ICD-10 resources and training materials will be available through CMS, professional associations and societies, software and system vendors.
CMS’ recommended training time suggests that health care providers start intensive training no sooner than six to nine months prior to the implementation for coders who will not assign ICD-10-CM/PCS codes until compliance date. Hospital inpatient coders will need to have 50 hours ICD-10-CM/PCS training. Other coders will require 16 hours of ICD-10-CM.
Health care providers will also need to confirm that billing services, clearinghouses and practice management software vendors are ready to provide the support they need in order to meet the compliance date.
Humana plans to conduct external end-to-end testing with a select group of early adopters during the second and third quarters of 2013. Health care providers who would like to participate in Humana’s testing may send an email to ICD10inquiries@humana.com for more information.
- Q: What is ICD-10?
A: ICD-10 stands for the International Classification of Diseases, 10th Edition. (ICD is the international standard for diagnostic classifications.) The current version, ICD-9, was adopted in 1979.
- Q: What does ICD-10 compliance mean?
A: A 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, 2014, implementation date.
- Q: What is the primary purpose of this change?
A: 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.
- Q: What changes are occurring in the ICD-10 version?
A: 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 about 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.
- Q: Who is affected by the transition to ICD-10?
A: All entities covered by HIPAA must transition to ICD-10. This includes both Medicare and commercial lines of business.
- Q: What happens if a covered entity doesn’t switch to ICD-10?
A: Claims that do not contain ICD-10 diagnosis and inpatient procedure codes for services provided on or after the implementation date will not be processed. They will be considered non-HIPAA compliant.
- Q: What is Humana's plan for ICD-10 acceptance?
A: 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?
A: Yes. Humana will go live with the ICD-10 codes effective October 1, 2014.
- Q: What is the deciding factor on when to use ICD-10 codes?
A: 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.
- Q: Will there be a period of time when both codes will be required on the same claim?
A: No. CMS has advised that ICD-9 codes will no longer be accepted on claims (including electronic and paper) that meet the following criteria:
- FROM dates of service or dates of discharge on or after October 1, 2014
- THROUGH dates (institutional claims and on professional and supplier claims) on or after October 1, 2014
A claim cannot contain both ICD-9 codes and ICD-10 codes. Institutional claims will be returned to the health care provider. Professional and supplier claims will be returned as not able to process.
- Q: Will Humana support dual processing of ICD-9 and ICD-10 codes?
A: 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, and after.
Humana will accept ICD-9 codes for dates of service prior to October 1, 2014, for the entire run-out cycle (taking into consideration account spanning dates).
- Q: Will Humana crosswalk incoming claims with ICD-9 codes to ICD-10?
A: 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.
- Q: Will Humana accept ICD-10 codes before the implementation date?
A: No. ICD-10 codes will not be accepted before the implementation date. Also, please note that claims with dates of service before the implementation date, but submitted after the implementation date, must use ICD-9 codes.
- Q: Will ICD-10 codes be required for authorization of services that occur after October 1, 2014?
A: Yes. ICD-10 codes will be required for dates of service after the implementation date.
- Q: What will the appeal process be for resubmission of ICD-9-based claims with ICD-10 codes during the transition period?
A: The appeal and resubmission process will follow the current process.
- Q: How will payment change with the transition to ICD-10?
A: 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.
- Q: Will Humana renegotiate provider contracts to replace ICD-9 codes with ICD-10 codes?
A: Yes. 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 a health care provider’s contract has specific ICD or DRG language, he or she should contact the appropriate market representative to facilitate a contract revision. Health care providers who are unsure how to locate their market representative may contact ICD10inquiries@humana.com.
- Q: Why is the transition to ICD-10 different from the annual code changes?
A: 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.
- Q: Will ICD-10 replace CPT coding?
A: No. CPT coding for outpatient procedures is not affected. ICD-10 procedure codes are for hospital inpatient procedures only.
- Q: Does Humana anticipate claim-processing issues with the preparation for ICD-10?
A: No. 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 help mitigate any such issues.
- Q: Will there be special handling for patients who are in-house over the transition?
A: No. Claims for patients in-house over the transition date should be submitted based on the “through” date, using recently published CMS recommendations.
- Q: How will Humana handle changes in payment with ICD-10?
A: 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.
- Q: Will DRG groupers continue to be based on ICD-9 codes, or will the grouper determine the DRG based upon ICD-10 codes?
A: CMS defines DRG codes. DRGs will be based on ICD-10 codes. We currently have DRG and ICD contract language in a small percentage of our contracts. If a health care provider’s contract has specific ICD or DRG language, he or she should contact the appropriate market representative to facilitate a contract revision.
- Q: What is Humana’s strategy to manage risks regarding provider contracts with stipulations on DRG and/or ICD codes?
A: 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.
- Q: Will Humana be using general equivalence mappings (GEMs) as part of its process, or for creating files coming in or out?
A: 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.
- Q: Is Humana working in collaboration with health care providers to transition to ICD-10?
A: 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. Health care providers who would like to participate in Humana’s testing may send an email to ICD10inquiries@humana.com for more information.
- Q: When will Humana begin ICD-10 testing?
A: Select provider testing is scheduled to occur in the third quarter of 2013. Health care providers who would like to participate in Humana’s testing may send an email to ICD10inquiries@humana.com for more information.
- Q: How does Humana plan to manage capitation reconciliations?
A: Humana does not expect any impact to capitation; our capitation reconciliation will follow the normal process.
- Q: How will Humana change medical necessity requirements as a result of the more specific codes that will be available?
A: Humana is reviewing and updating its medical policies to incorporate new ICD-10 terminology and expanded coding.
- Q: Will Humana update medical review policies, coverage determinations and payment determinations?
A: Yes. Humana is in the process of reviewing and updating its medical policies to incorporate new ICD-10 terminology and expanded coding.
- Q: Will any reporting formats change?
A: Yes. Any reporting formats that include ICD-9 today will be remediated to reflect the ICD-10 codes.
- Q: When will Humana begin testing transactions?
A: Humana will begin testing ICD-10 transactions in the second quarter of 2013.
- Q: Will there be extensions given for timely filing during the ICD-10 transition time?
A: No. Humana does not expect any timely filing extensions at this time.
- Q: How long will Humana provide support for both ICD-9 and ICD-10 coding?
A: Humana will accept ICD-9 codes for dates of service prior to October 1, 2014, for the entire run-out cycle (taking into consideration spanning dates) and timely filing requirements.
- Q: Does the health plan provide regular and ongoing communication to health care providers regarding ICD-10 efforts and status?
A: Yes. The ICD-10 Program Team has a communication plan and schedule for keeping Humana’s testing partners, trading partners, health care providers and internal departments informed. Humana will keep health care providers posted using the ICD-10 page on this website and via Humana’s YourPractice.
- Q: What key information should health care providers keep in mind as they develop their own ICD-10 implementation plans?
A: Humana suggests 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 resources listed below. If health care providers have questions or concerns, they may submit an email to ICD10inquiries@humana.com.
This information is only a high-level summary of certain provisions of the health care reform law. This information does NOT attempt to summarize all provisions of the health care reform law. This information is not and should NOT be used as legal or tax advice; it should not be used as a basis for decisions regarding how health care reform law will affect you and/or your business. Should you have any questions on how the health care reform law (including the high level summary of certain provisions of health care reform) will affect you and/or your business, you should seek professional advice from attorneys or other advisors.
