ICD-10 frequently asked questions and answers

The following is how Humana identifies the provider community:

  • Fee-for-service providers, who submit claims for all contracted services.
  • Capitated providers, who submit capitated encounters and are paid per member/per month.
  • Claim delegates, who contract with Humana and pay/process claims on behalf of Humana. The delegates contract independently with physicians and hospitals or through Medical Service Organizations (MSOs) and submit delegated encounters to Humana.


  • 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: An entity covered by the Health Insurance Portability and Accountability Act (HIPAA) must be able to successfully conduct health care transactions using ICD-10 diagnosis and procedure codes. ICD-9 diagnosis and procedure codes can no longer be used for services provided on or after the Centers for Medicare & Medicaid Services (CMS) implementation date of Oct. 1, 2015.

  • Q: What is the primary purpose of this change?

    A: 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. Also, it will enable the United States to exchange information across international borders. The World Health Organization uses the ICD code set to track mortality and comorbidities on a global level.

  • Q: What changes are occurring in ICD-10?

    A: ICD-10 changes impact ICD-9 Clinical Modification (CM) diagnosis codes and ICD-9-CM procedure codes.

    • The diagnosis codes for ICD-9 are three to five digits, which are alphanumeric in nature and combine to make more than 14,000 unique diagnosis codes.
    • ICD-10 diagnosis codes will be three to seven alphanumeric digits that combine to make more than 69,000 unique diagnosis codes.
    • ICD-9 procedure codes are three to four numeric digits that combine to make about 4,000 unique procedure codes.
    • ICD-10-PCS (inpatient) procedure codes will be seven alphanumeric digits that combine to make approximately 72,000 unique procedure codes.

  • Q: How and why is ICD-10 code set beneficial?

    A: The current coding system can’t take health care into the future. The American Health Information Management Association (AHIMA) lists the following among the benefits1:

    • Quality measurement: The codes have the potential to provide better data for evaluating and improving the quality of patient care.
    • Outcomes measurement: Data captured by the code sets could be used in more meaningful ways to better understand complications and track care outcomes.
    • Health policy planning: ICD-10 is more specific and fully captures more of the nationally reportable public health diseases.
    • Research: Code analysis is an essential component of research in which there is no direct access to patient medical records.
    • Evaluating new procedures: Finer distinctions in the data offer a more precise evaluation of new medical procedures.

  • Q: Why can’t the industry skip to ICD-11?

    A: The World Health Organization (WHO) is anticipating a release of ICD-11 in 2017, but AHIMA says the need to adapt it as a HIPAA code set standard could take 10 years or more, based on the ICD-10 experience.2

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

    A: All entities covered by HIPAA must transition to ICD-10. This includes Medicare, Medicaid and commercial lines of business.

  • 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 have three to five characters, whereas ICD-10 codes will be alphanumeric and contain up to seven characters.

  • Q: Can I expect Health and Human Services (HHS) to grant an extension beyond the October 1, 2015 compliance date?

    A: All HIPAA-covered entities must implement the new code sets with dates of service, or dates of discharge for inpatients, that occur on or after October 1, 2015 in order for the claims to be processed.



  • 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: Will there be a grace period for providers to submit ICD-9 and/or ICD-10 codes?

    A: No. Per CMS, the compliance date for ICD-10 is Oct. 1, 2015

  • Q: Why is ICD-10 transition necessary?

    A: The primary reason is that it is the law. Legislation was passed in 2009 that mandated the use of the ICD-10 code set.


  • Q: What is capitation?

    A: Providers who have entered into a capitated agreement with Humana will receive a check per member/per month (PMPM) regardless of whether they see the member. Capitation may be paid to primary care providers (PCP) and specialist groups with which the PCPs are contracted, such as dermatology, cardiology, etc.

  • Q: What are the capitation rates?

    A: Capitation amounts can be a flat rate calculated by Humana or a percentage of premium determined by CMS.

  • Q: How does Humana plan to manage capitation reconciliations with ICD-10?

    A: Humana does not expect an impact to capitation. Our capitation reconciliation will follow the normal process.

Diagnosis-Related Group (DRG)

  • Q: Will DRG groupers continue to be based on ICD-9 codes?

    A: No. CMS defines DRG codes. DRGs will be based on ICD-10 codes when ICD-10 is implemented per the compliance date.

  • 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:

    • A DRG change has taken place, or
    • A contract has been rewritten to incorporate a change of reimbursement.
    Additionally, code editing based on a diagnosis/procedure will apply per the current adjudication process.

  • Q: What DRG grouper logic is Humana using and are the DRGs being optimized for ICD-10?

    A: We are currently using version 30 DRG grouper logic. We will continue to transition to the latest groupers as they are released by CMS.


  • Q: What is an encounter?

    A: An encounter is a unique type of claim. Encounter data is used to determine the member’s health status. Encounter data is submitted by health care providers who have a capitated agreement with Humana or who are delegated for claims.

  • Q: Why are encounters critical?

    A: Although encounters do not generate payments to the rendering provider, encounter information is used for Healthcare Effectiveness Data and Information Set (HEDIS) reporting. Also, encounters are a primary driver for risk adjustment scoring.

  • Q: How do encounters impact the member/provider?

    A: If encounters do not describe the conditions of a Medicare Advantage member completely and accurately, there may be a negative impact to the member’s risk score and to the related reimbursement from CMS. Risk scores are higher for members with greater levels of illnesses. If diagnosis codes are missing on a member’s encounter, then the risk score assigned to the member may be understated.

  • Q: Which diagnosis codes need to be included on the claim/encounter?

    A: Encounters/claims must contain all diagnosis codes for which the member was treated and/or monitored during his or her visit.

Health Care Services Review (278)

  • Q: Did Humana’s companion guide change with ICD-10?

    A: No. However, after the compliance date providers should follow the implementation guide for proper coding.

Humana’s readiness

  • Q: What are Humana’s top areas of concern related to provider ICD-10 readiness?

    A: There are several areas of concern:

    • Accurate use of ICD-10 coding for claims submitted on or after the compliance date
    • Vendor readiness to support ICD-10 early enough for providers to prepare
    • Delegate/provider readiness to submit fully loaded encounter data
    • Rendering providers’ readiness to support ICD-10 on or after the compliance date

  • Q: Will Humana accept ICD-10 codes before the implementation date?

    A: No. ICD-10 codes will not be accepted before the implementation date. Please note that claims with dates of service before the implementation date, but submitted after the implementation date, must use ICD-9 codes.

  • Q: Does Humana plan to be ready to process ICD-10 codes submitted on claims forms by the compliance date?

    A: Yes.

  • Q: Does Humana provide regular and ongoing communication to health care providers regarding ICD-10 efforts and status?

    A: Yes. Humana’s 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 site located on the provider portal, as well as Humana’s YourPractice, Humana’s online provider newsletter.

    You may visit the ICD-10 site at the following address:

    You may also visit Humana’s YourPractice:

    Choose the link to “Humana’s YourPractice.”

  • Q: When will Humana’s ICD-10 upgrades be complete?

    A: Humana’s ICD-10 program began in 2009 and has been a continuous remediation effort. Humana is now in the external testing phase, which will continue through the compliance date. Humana’s system remediation changes will not be visible to providers.

  • Q: What is Humana’s plan to minimize potential increases in denials and appeals?

    A: Humana will process all correctly coded claims mirroring the current time frames. Denials and appeals will follow the existing process.

  • Q: Is Humana working in collaboration with health care providers to transition to ICD-10?

    A: Yes. Humana began conducting external end-to-end testing with a select group of early adopters (facilities) in the third and fourth quarters of 2012. We will begin testing with a select group of physicians and claim delegates in early 2015.

  • Q: Will you follow CMS's Local Coverage Determination (LCD) and National Coverage Determination (NCD) policies for medical necessity?

    A: Yes. Humana will follow CMS's policies.

ICD-9 to ICD-10 processing plan

  • Q: Will Humana be accepting ICD-10 coded claims in advance of the compliance deadline?

    A: No. Humana will not accept ICD-10 codes prior to the ICD-10 implementation date.

  • Q: Has Humana defined the process for readmission claims within 30 days?

    A: Yes. Humana will follow the current claims submission process.

  • Q: What is Humana's plan for ICD-10 acceptance?

    A: Humana will support both ICD-9 and ICD-10 coding formats for a period of time after the compliance date. However, Humana will accept only correctly formatted claims, both electronic and paper, which contain ICD-10 codes for service dates and discharge dates on or after the compliance date. Humana will accept ICD-9 codes for service dates or discharge dates prior to the compliance date for the contracted run-out period or timely filing requirements.

  • Q: Does Humana anticipate claims-processing issues with the preparation for ICD-10?

    A: No. Humana has invested in remediation of systems and processes to support ICD-10 requirements. Humana does not foresee issues with claim processing with the change to ICD-10. Testing will help mitigate such issues.

  • Q: Can one claim be submitted for services that span the new CMS proposed compliance date of Oct. 1, 2015?

    A: FOR OUTPATIENT SERVICES ONLY No. Per CMS, Humana will require claims with dates of service that extend past the compliance date to be split into separate claims. This means that all services that occur before the compliance date should use ICD-9 codes and should be billed separately from services with dates of service on or after the compliance date, which should contain only ICD-10 codes.

    A: FOR INPATIENT SERVICE ONLY Yes. The date of discharge will determine which ICD code set should be used. For inpatient services, if the date of discharge is on or after the compliance date, the claim should be submitted using only ICD-10 codes. If the date of discharge is before the compliance date, ICD-9 codes should be used.

    Humana will follow CMS or current state filing requirements.

  • Q: How will Humana handle authorization of services that occur on or after the ICD-10 compliance date?

    A: We will follow Humana’s current process, which is to issue authorizations based on request date.

    • If an authorization is requested on or before the compliance date, and the date of service is on or after Oct. 1, 2015 providers should submit an ICD-10 code.
    • If the authorization is requested after the compliance date, the ICD-10 code will be required.
    • Humana will begin accepting ICD-10 codes for authorizations and referrals on July 1, 2015 and will not accept any ICD-9 authorization codes after Oct. 1, 2016.

  • 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 be the same as the current process.

  • Q: Will there be extensions given for timely filing during the ICD-10 transition time?

    A: No. Humana does not anticipate the use of timely filing extensions at this time.

  • Q: Will reporting formats change?

    A: Yes. Reporting formats that include ICD-9 today will be remediated to reflect ICD-10 codes.

  • Q: Will your remediation plans vary by product or platform?

    A: No. ICD-10 will be applied through all products and platforms.

  • Q: If I submit or process a transaction with an ICD-9 code for a date of service after the compliance date, will I be HIPAA-compliant?

    A: No. The date of service determines the compliant code format to be used on a claim regardless of the date the claim is filed or submitted.

    • Providers must submit claims before the compliance date with ICD-9 codes when the services were performed prior to the compliance date.
    • Payers will process claims if received on or after the compliance date with ICD-9 codes when the services were performed prior to the compliance date. This situation is HIPAA-compliant.

  • Q: Will you accept 837 batches with both ICD-9 and ICD-10 claims spanning the conversion deadline?

    A: Yes. Humana will accept 837 batches containing both ICD-9 and ICD-10 claims as long as both codes are not contained on the same claim.

  • Q: What are the plans for restrictions on the acceptance of the unspecified codes for ICD-10?

    A: Humana will follow current CMS guidelines.

  • Q: Would Humana agree to prospective experienced-based payments with retro adjustments (likely to happen at a future date) should your adjudication system fail?

    A: No. Humana will not agree to experienced-based payments.

  • Q: Are there companion guides to reflect ICD-10 changes?

    A: Yes. Here is the link to our companion guides:

  • Q: Will claims that don’t meet specifications be rejected at point of receipt or will a denial be issued?

    A: They will be rejected at point of receipt.

  • Q: Will the claim resubmission process change with ICD-10?

    A: No. Provider resubmission processes will continue to follow current guidelines.

  • Q: How will the transition from ICD-9 to ICD-10 work with eligibility transactions and subsequent episodes of care?

    A: All eligibility transactions using a diagnosis code must be compliant with ICD-10 upon the compliance date.

  • Q: Does Humana require/support interim billing?

    A: No. Humana does not support interim billing.

  • Q: What customer support and training will be provided to providers?

    Humana publishes current ICD-10 information on its provider website:

    Providers should continue to access the CMS website for the most current ICD-10 information:


  • Q: What are General Equivalence Mappings (GEMs)?

    A: General Equivalence Mappings (GEMs) are a CMS translation tool that can be used to convert data from ICD-9 to ICD-10. According to the CMS, GEMs are useful in converting databases but are not a substitute for learning how to use ICD-10 codes. Mapping links the two code sets without considering the patient medical record information. Coding involves choosing the appropriate code based on the medical record documentation.

  • Q: Will Humana be using CMS GEMs as part of its process?

    A: Yes. Humana is using CMS GEMs as a guideline to map ICD-9 codes to ICD-10 codes.

  • 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.

Medicaid Risk Adjustment

  • Q: What is Medicaid Risk Adjustment?

    A: Medicaid Risk Adjustment protects beneficiary access to services and the financial condition of providers and health plans by providing payment based on beneficiary health status. In Medicaid, the conditions that are risk adjusted are called Disease Categories.

  • Q: Will Medicaid Risk Adjustment be affected by ICD-10?

    A: Medicaid plans vary by state, but the key to accurate Medicaid reimbursement is to code accurately and to the highest level of specificity to ensure the Disease Categories are triggered, if warranted.

Medical policy and medical necessity

  • Q: How will Humana update medical necessity requirements, as well as policies, coverage determinations and payment determinations, as a result of the more specific codes that will be available?

    A: Humana has reviewed and updated its medical policies to incorporate new ICD-10 terminology and expanded coding. Humana publishes medical policies on its provider website at Choose “For Providers” then select “Medical and pharmacy coverage policies” under the “Resources” heading. Humana has updated medical policies to reflect ICD-10 changes.

Medicare Advantage hierarchical condition categories

  • Q: What is a hierarchical condition category (HCC)?

    A: HCCs represent categories of health conditions, both chronic and acute, that are used to project health care costs for Medicare Advantage members for an upcoming coverage period. Diagnosis codes are mapped to HCCs for conditions such as diabetes, congestive heart failure, etc. Members may have multiple HCCs.

  • Q: When will CMS release HCCs for ICD-10?

    A: CMS posted a preliminary ICD10-HCC crosswalk on Feb. 24, 2014. There are approximately 10,100 diagnosis codes that have been identified as appropriate for Medicare risk adjustment, and these are mapped to the various HCC models. In April 2015, CMS is expected to release updated ICD-10 mappings that will go into effect on October 1, 2015. CMS has not released any crosswalk for commercial lines of business.

  • Q: How do HCCs contribute to a member’s risk score?

    A: Each HCC is assigned a decimal value that contributes to the member’s risk score.

Medicare Risk Adjustment

  • Q: What is risk adjustment?

    A: Risk adjustment is a process in which per-member reimbursements from CMS are adjusted to correspond with the member’s health status, which is based upon submitted diagnosis codes. When encounters are not submitted, Humana and CMS do not have complete member information. Risk adjustment was implemented to pay Medicare Advantage plans more accurately for predicted health cost expenditures for members by adjusting payments based on demographics (e.g., age and gender) as well as health status.

  • Q: How does risk adjustment impact physicians and members?

    A: Increased coding accuracy helps Humana identify members who may benefit from disease and medical management. Accurate health information is used to match health care needs to the appropriate level of care.

Outpatient vs. inpatient

  • 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 on or after the compliance date.

  • Q: Will ICD-10 replace Current Procedural Terminology (CPT®) or Healthcare Common Procedure Coding System (HCPCS) coding?

    A: No. CPT and HCPCS coding for outpatient procedures are not affected. ICD-10 procedure codes apply to hospital inpatient procedures only.

  • Q: Will there be special handling for patients who are in-house over the transition?

    A: Yes. Claims for patients in-house over the transition date should be submitted based on the discharge date, using the most recent CMS recommendations.

Provider readiness

  • 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 changes from CMS regarding ICD-10 implementation via the CMS website as well as other resources listed at the end of the document.

  • Q: Will providers need to learn thousands of potential new codes?

    A: Not necessarily. Though ICD-10 allows for many more coding possibilities, specialists will typically use a much narrower range of diagnosis and procedure codes. The American Academy of Professional Coders (AAPC) has published the top 50 code sets for 16 specialties. 10/crosswalks/pdf-documents.aspx

  • Q: Is it true that hard copy ICD-10 code books will not be available and all coding will have to be performed electronically?

    A: No. ICD-10-CM and ICD-10-PCS code books are already available and are a manageable size, per CMS.

  • Q: Will Humana renegotiate provider contracts to replace ICD-9 codes with ICD-10?

    A: Yes. We currently have diagnosis-related groups (DRG) and ICD contract language in a small percentage of our contracts, and Humana will work with health care providers to update contracts where required. 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. If you are unsure how to locate your market representative, please contact provider relations at 1-800-626-2741.

  • Q: How can providers find out if they are required to purchase additional hardware, software license and/or subscription fees to support ICD-10 changes or enhancements?

    A: Please contact your software vendors for requirements.

  • Q: Do you have ICD-10-related information we can subscribe to or a point of contact for more information?

    A: Humana posts ICD-10 information on its provider website at the following URL: providers/education/claims/icd-10/

    Additionally, you may send an email to:


  • Q: Do you anticipate any changes in policies or delays in payments to result from the switch to ICD-10?

    A: Humana does not expect any delay in payment or process to the way a claim is adjudicated using an ICD-10 code if the claims are properly coded based on the latest CMS guidelines; although rejection due to misuse of new codes is possible.

Service Fund reports and data files

  • Q: What are the Service Fund reports?

    A: Service Fund reports include the following: claim reports RE627, 767 and data files RECLM627, RECLMDSP and RECLMEXP. Reports and data files contain ICD-10-level details.


  • Q: Will Humana train providers’ medical coders?

    A: No. Humana will not offer training to health care providers or coders who are not employed by Humana.

    For more information or training regarding the transition to ICD-10, Humana suggests contacting the American Medical Association, CMS, Workgroup for Electronic Data Interchange (WEDI), American Health Information Management Association (AHIMA), American Academy of Professional Coders (AAPC) or other associations that provide ICD-10 training directly to health care providers.

Other resources:

IMPORTANT: The information contained on this website is designed to provide a general overview of what can be expected with the transition from the International Statistical Classification of Diseases and Related Health Problems, Ninth Revision, (ICD-9) to ICD-10 as it impacts Humana’s business. The information provided is not intended to address all of the Centers for Medicare & Medicaid Services (CMS) requirements and implications mandating the use of ICD-10 and should not be used as legal advice for implementation activities. We encourage you to seek any professional advice you may need, including legal counsel, regarding how the new requirements will affect your specific practice. Humana is providing the information on this site for general informational purposes only.