The Center of Medicare & Medicaid Services (CMS) ICD-10 compliance date is October 1, 2015. We are ready to accept ICD-10 codes on claims based on dates of service (outpatient) or dates of discharge (inpatient). The change to ICD-10 does not affect CPT coding for outpatient procedures and physician services.
Providers are required to submit Health Insurance Portability and Accountability Act (HIPAA)-compliant transactions in version 5010. As of October 1, all HIPAA-covered entities must use the new ICD-10 code sets.
The ICD-9 code sets are out-of-date due to their limited ability to accommodate new procedures and diagnoses. ICD-10 incorporates greater specificity of codes - more clinical information contained in the codes - and updated terminology.
Use of ICD-10 will:
- Improve the ability to measure health care services
- Enhance the ability to monitor the populations' health
- Provide better overall data and decrease the need for supporting documentation needed when submitting claims
What is ICD-10?
Effective October 1, 2015, all health care entities must use ICD-10 codes on HIPAA transactions, including:
- Diagnosis codes (ICD-10-CM) used by all providers in every health care setting
- Procedure codes (ICD-10-PCS) only used for hospital claims and inpatient hospital procedures
What are the effective dates?
After October 1, 2015, we will process claims submitted with ICD-9 codes only for dates of service (outpatient) or dates of discharge (inpatient) prior to the October 1 compliance date.
What is different?
ICD-10 codes length and structure differ from ICD-9 codes. In addition, ICD-10 codes:
- Contain more detail about conditions, injuries and illnesses
- Include the concept of laterality
- Use combination codes to describe conditions and associated symptoms
- Use updated language and terminology
Will the ICD Indicator be required on paper claim submissions?
Yes. The use of ICD indicators will be required on all paper claims (UB-04 and CMS-1500). Claims submitted without ICD indicators or with invalid ICD indicators will be rejected with a message stating that the ICD indicator is required. In the ICD indicator field on the claim form, located in box 21 of the 02/12 version of CMS-1500, and box 66 of the UB-04, enter the number “0” to indicate ICD-10 or “9” to indicate ICD-9.
CMS recently stated that they will allow for one year leniency for certain Medicare Part B claims. What is the Health Plan’s position on the one year leniency?
We will not allow leniency with specificity and will expect the exact code. We will not adjust our position regarding ICD-10 code processing based on the change from CMS. We are not making any specific system or process changes related to specificity relaxation. We will follow the coding guidelines as defined by the CMS mandate based on the time frame defined by the mandate, and we will require coding specificity within the family group to ensure appropriate claims payment.
Who can I contact with ICD-10 related questions?
Provides should follow the same process that is in place today for addressing claim related issues. Specific questions regarding ICD-10 should be directed to Customer Care or Provider Relations. All Questions will be triaged to the appropriate person or department.
What is our health plan’s position on ICD-10 implementation?
- We have remediated all of our systems to be ICD-10 compliant.
- Follow this link to read more about our end-to-end testing process and what we learned from testing.
- Follow this link to learn more about our position on ICD-10 implementation (PDF).