- 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 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?
- 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.
- 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 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.
- 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:
Additionally, you may send an email to: