Answers to Provider Questions about ICD-­‐10 Industry Questions (not specific to a health plan/payer) Answers to most of the questions that you will find in the tables below are provided by CMS. For questions that have been
answered by CMS, clicking on the question itself will take you directly to the appropriate CMS page. For some questions,
additional comments and/or resources are also provided.
•
Clicking on any of these questions will go to the following CMS document that contains the answers:
https://www.cms.gov/ICD10/Downloads/ICD10FAQs.pdf
•
Clicking on any of these questions will go to the following CMS page that contains links to CMS Implementation Guides
– one for each type of provider organization. Select the Guide that is appropriate to your organization. The questions
will be answered in that handbook. http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html
Note: CMS indicates that the content on their website may not be up to date. Accuracy of the information on the CMS
web site is the responsibility of CMS.
Questions
1. How are ICD-10 codes different from
ICD-9 codes?
2. How soon are the ICD-10 codes going
to be published for entry into our
system?
Comments /Additional Resources
The 2012 ICD-10 code sets have been published and are available on the CMS and
CDC websites
*See
http://www.cms.gov/Medicare/Coding/ICD10/2012-ICD-10-CM-and-GEMs.html
General
Background
ICD - ICD-10-CM - International Classification of Diseases, Tenth Revision,
Clinical Modification
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3. How will ICD-10 impact Current
Procedural Terminology (CPT) and
Healthcare Common Procedure Coding
System (HCPCS) codes?
4. Is there an overlap between ICD-10
PCS (PCS – Procedure Coding
System) and CPT?
Comments /Additional Resources
No. ICD-10 PCS is a different coding system than CPT utilizing 7 digits and is
alpha-numeric.
ICD-10-PCS will be used to report hospital inpatient procedures only. Like ICD-9
Will any health plans require
ICD10-PCS to be put on outpatient
claims?
procedure codes, ICD-10- PCS codes are for hospital inpatient procedures only.
The specification for the HIPAA mandated 837-claims transaction prohibits PCS
codes from being submitted on an outpatient claim.
The switch to ICD-10 does not affect CPT coding for outpatient procedures. The
Current Procedural Terminology (CPT) and Healthcare Common Procedure
Coding System (HCPCS) will continue to be used to report services and
procedures in outpatient and office settings.
*See
http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-yourpractice/coding-billing-insurance/hipaahealth-insurance-portability-accountabilityact/transaction-code-set-standards/icd10-code-set.page
5. Does the ICD-10-CM contain
procedure codes?
6. When do we need to stop using ICD-9
CM/PCS and start using the ICD-10CM (diagnoses) and ICD-10-PCS
(procedures) codes?
All services rendered on and after October 1, 2015 that are billed on a CMS1500/837P claim must be coded with ICD-10.
All claims with a discharge date on and after October 1, 2015 that are billed on a
UB-04/837I must be coded with ICD-10. See MLN article for exceptions and
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Comments /Additional Resources
special circumstances.
*See
MLN Article
https://www.cms.gov/MLNMattersArticles/downloads/MM7492.pdf
See ICD-10 Final Rule
http://edocket.access.gpo.gov/2009/pdf/E9-743.pdf
7. On claims, may we use the ICD-10
codes before October 2015 if we are
ready?
8. When will the ICD-9 codes stop being
accepted?
ICD-10 codes must not be submitted for dates of service/discharge prior to
October 2015. However, ICD-10 codes can be submitted prior to the
implementation for purposes of collaborative testing with payers and other trading
partners
*See
MLN Article
https://www.cms.gov/MLNMattersArticles/downloads/MM7492.pdf
As long as the date of service/discharge is prior to October 1, 2015, ICD-9 codes
will still be valid. Because of claims timely filing limits, appeals, retroactive
coverage and other administrative processes can span the implementation date, the
length of time that ICD-9 codes can be accepted will vary by payer.
*See
MLN Article
https://www.cms.gov/MLNMattersArticles/downloads/MM7492.pdf
https://www.cms.gov/MLNMattersArticles/downloads/SE0832.pdf
9. Are the ICD-10 code sets final? Will
https://www.cms.gov/ContractorLearningResources/downloads/JA0832.pdf
Yes. The last regular, annual updates to both ICD-9-CM and ICD-10 code
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changes be made to them?
10. How often will the ICD-10 codes be
updated?
Comments /Additional Resources
sets were made on October 1, 2011. As of October 1, 2012, there will be
only limited code updates to both the ICD-9-CM and ICD-10 code sets to
capture new technologies and diseases as required
Just like ICD-9, ICD-10 codes will be updated annually and effective every
October 1st.
*See
https://www.cms.gov/ICD9ProviderDiagnosticCodes/03_meetings.asp
11. What healthcare providers/settings are
impacted by the transition to ICD-10?
12. Can we expect a new Diagnosis
Related Group (DRG) coding scheme?
If so, when will this version be
released?
The Medicare Severity Diagnosis Related Groups (MS-DRG) have been converted
to ICD-10. For specific questions about any possible impact with your health
plan(s), reach out to them directly.
*See
http://www.cms.gov/ICD10/17_ICD10_MS_DRG_Conversion_Project.asp#TopO
fPage
13. What is Medicare’s plan to update the
HCC (Hierarchical Condition
Categories) and their corresponding
payment methodology?
14. Should we expect updates to the
Impairment Group Codes (for Rehab,
SNF, etc)? If so, when?
According to the CMS ICD-10 Impact Analysis, Impairment Group Codes will be
translated to ICD-10 which will impact current CMS business processes. No
specific dates are indicated for these updates to the Impairment Group Codes.
The complete CMS ICD-10 Impact Analysis can be found at:
http://www.cms.gov/Medicare/Coding/ICD10/CMSImplementationPlanning.html
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15. Will behavioral health providers who
currently use DSM-IV diagnosis codes
need to change to ICD-10?
Comments /Additional Resources
Click the embedded link "ICD-10 Impact Analysis" in the last paragraph under the
section "CMS ICD-10 Impact Analysis".
Yes. DSM-V is scheduled to be published in May 2013 and will include ICD-10
diagnosis codes.
*See
http://www.dsm5.org/Pages/Default.aspx
16. Are all providers currently using ICD-9
required to change to ICD-10?
17. Are any providers exempt from having
to use ICD-10 codes?
18. Does the ICD-10 mandate apply to
paper claims?
All providers designated as a HIPAA covered entity must use ICD-10.
*See
http://www.cms.gov/ICD10/Downloads/ICD-10MythsandFacts.pdf
ICD-9 codes will no longer be accepted on claims (including electronic and paper)
with dates of service (on professional and supplier claims) or dates of
discharge/through dates (on institutional claims) on or after October 1, 2015.
*See
http://www.cms.gov/MLNMattersArticles/Downloads/MM7492.pdf
19. Some insurance companies only accept
paper claims, especially for secondary
claims. Will the CMS 1500 form itself
be updated to allow for the longer
codes and if so, when will these be
available?
20. What is the relationship between the
5010 and the ICD-10 codes?
21. Why is there an ICD-11 coming soon?
Why not include the ICD-11 codes in
Yes. The National Uniform Claims Committee (NUCC), who owns and maintains
the CMS 1500, has updated the form to accommodate ICD-10.
*See
http://www.nucc.org/index.php?option=com_content&view=article&id=186&Item
id=138
ICD-10 was developed and published by the World Health Organization in 1994.
The ICD code set is typically updated every 10 years. The US is the last
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the ICD-10 implementation?
Comments /Additional Resources
industrialized nation to adopt ICD-10 for reporting diseases and injuries. ICD-11 is
scheduled for release by the WHO in 2015. However, it will need to be modified
for use in the U.S. before it can be implemented.
*See
http://www.who.int/classifications/icd/revision/en/index.html
1.
Is there a crosswalk from ICD-9 codes
to ICD-10 codes?
2.
Is there a crosswalk from ICD-10
DRGs to ICD-9 DRGs?
Mapping
ICD-9 to
ICD-10
What DRG versions are ICD-10
compliant?
No. It is not possible to crosswalk codes from ICD-9 to ICD-10. However, there
are General Equivalence Mappings or GEMs which are available on the CMS
website.
(See question above about GEMS)
No. It is not possible to crosswalk DRGs from ICD-9 to ICD-10.
MS-DRG: A new version of the MS-DRG Definitions Manual is produced each
year. MS-DRG v.30 and v.31 are ICD-10 compliant groupers that are currently
available. MS-DRG v.32 is projected for implementation in October 2014. For
additional information: http://www.cms.gov/Medicare/Coding/ICD10/ICD-10MS-DRG-Conversion-Project.html
AP-DRG: AP-DRG is not being updated to be ICD-10 compliant.
APR DRG: APR-DRG v.30 and v.31 are ICD-10 compliant groupers. Initial
release date for v.30 was on October 1, 2012. Between 10/01/2013 and
10/01/2015, new versions of the APR DRG grouper will be available each year,
including an ICD-9 and an ICD-10 version each year. The table below shows how
long the ICD-10 version of each APR DRG grouper will be supported:
APR ICD-10 version
31.0
32.0
33.0
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2014
2015
2016
Date available
10/01/2013
10/01/2014
10/01/2015
Date support ends
10/01/2016
10/01/2016
10/01/2022
3.
•
•
•
Questions
What are the General Equivalent
Mappings (GEMs)?
How do they work and why are they
used?
Are they designed for all providers
and payer or just CMS and Medicare?
Are they finalized and for how long
will they be maintained?
Comments /Additional Resources
“There is no simple crosswalk from ICD-9 to ICD-10 in the GEM files. A mapping
that forces a simple correspondence—each ICD-9 code mapped only once—from
the smaller, less detailed ICD-9 to the larger, more detailed ICD-10 defeats the
purpose of upgrading to ICD-10. It obscures the differences between the two code
sets and eliminates any possibility of benefiting from the improvement in data
quality that ICD-10 offers. Instead of a simple crosswalk, the GEM files attempt to
organize those differences in a meaningful way, by linking a code to all valid
alternatives in the other code set from which choices can be made depending on
the use to which the code is put.” ~ 2012 ICD-10-CM GEM Users Guide.
The GEMs are a crosswalk tool developed by CMS and CDC for use by ALL
providers, payers, and data users. The mappings were finalized in December 2011
are available for free on the CMS website.
The GEMs can be used to become acquainted with ICD-10 as well as the basis for
software that can be used to help analyze the impacts of ICD-10 and
implementation activities. CMS anticipates maintaining the GEMs for a minimum of 3 years after
implementation.
*See
http://www.cms.gov/ICD10/11b14_2012_ICD10CM_and_GEMs.asp#TopOfPage
http://www.cms.gov/ICD10/Downloads/ICD-10MythsandFacts.pdf
http://www.cms.gov/ICD10/05a_ProviderResources.asp#TopOfPage
4.
Is there a GEMs mapping from ICD10 PCS to ICD-9 PCS?
http://www.cms.gov/ICD10/17_ICD10_MS_DRG_Conversion_Project.asp#TopO
fPage
Yes
http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-PCS.html Download
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5.
6.
Is there a user friendly version of the
GEMs crosswalk?
As a contingency plan for submitting
claims to health plans that may not
ready on 10/1/15, are there ICD-10
codes that do not map back to ICD-9
codes?
Comments /Additional Resources
2014 General Equivalence Mappings (GEMs) – Procedure Codes and Guide [ZIP,
721KB]
Not from CMS. Vendors may provide for free or license tools.
Due to the differences in the code sets, there are some concepts that do not carry
over to ICD-10 as well as there are new concepts in ICD-10 that do not exist in
ICD-9. In some cases an ICD-9 code or group of codes may not have an ICD-10
counterpart and would therefore be considered as a “No Map”. For more
information, download the GEM Users Guide.
*See
http://www.cms.gov/ICD10/11b14_2012_ICD10CM_and_GEMs.asp#TopOfPage
7.
What are the Reimbursement
Mappings?
“The Reimbursement Mappings were created to provide a temporary but reliable
mechanism for mapping records containing ICD-10 diagnosis and procedure codes
to “reimbursement equivalent” ICD-9 diagnosis and procedure codes, so that while
systems are being converted to process ICD-10 claims directly, the claims may be
processed by the legacy systems.” ~ Reimbursement Mappings User’s Guide
*See
http://www.cms.gov/Medicare/Coding/ICD10/index.html (click on the appropriate
‘GEMS’ link on the left side of the page)
8.
Where an ICD-10 code maps to a
cluster of ICD-9 codes – will the
GEMS file provide guidance on how
to sequence codes on an outbound
claim.
(May be relevant when submitting post
10/1/2015 claims to payers that are not
ready to and/or not required to accept
No. For those instances when an ICD-10 code maps to a ‘cluster’ of ICD-9 codes,
and all codes in that cluster must be included on a claim, refer to the coding
guidelines for clarity around sequencing.
Coding Guidelines can be found at:
CDC Website
http://www.cdc.gov/nchs/icd/icd10cm.htm
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ICD10 codes, e.g. workman’s comp, auto
insurers.)
Comments /Additional Resources
http://www.cdc.gov/nchs/data/icd10/10cmguidelines_2013_final.pdf
CMS Website
http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-PCS.html
Download 2014 General Equivalence Mappings (GEMs) – Procedure Codes and
Guide [ZIP, 721KB]
1.
What will happen if providers
currently using ICD-9 codes do not
adopt ICD-10-CM and ICD-10-PCS?
Compliance
Claims submitted with ICD-9 codes after October 1, 2015 for dates of
service/discharge on and after October 1, 2015 will risk denial and nonpayment.
Claims submitted to Medicare with ICD-9 codes after implementation will be
denied. Additionally, providers submitting claims via 5010 after the compliance
date will be in violation of HIPAA Transactions & Code Sets rules and will risk
penalties for non-compliance.
*See
https://www.cms.gov/ICD10/Downloads/ICD-10Overview.pdf
http://edocket.access.gpo.gov/2009/pdf/E9-743.pdf
2. Is Medicaid required to switch to ICD10?
3. Are all insurance carriers required to
use ICD-10 by the same deadline as
providers? If all carriers are not
required to implement ICD-10, which
ones are exempt and why?
Worker’s Compensation and Property & Casualty insurers are not required to use
ICD-10 codes as they are not considered, at this time, to be HIPAA covered
entities. However, individual insurers of these 2 types may choose to adopt the
new code sets. Washington State Labor & Industries is implementing the
ICD-10 codes sets by October 2015.
*See
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Claims
Processing
Comments /Additional Resources
http://www.cms.gov/ICD10/Downloads/ICD-10MythsandFacts.pdf
4. Will there be a grace period for
implementation of ICD-10
compliance?
The ICD-10 compliance date is firm and currently there is no grace period.
5. Who are the ICD-10 compliance
“police”? Who would a provider or an
insurance company contact if one or
the other was not complying?
CMS is responsible for monitoring and enforcing non-privacy related HIPAA
violations. Any violations would be reported to CMS using the required form.
1. What if I have claims for dates of
service prior to October 1, 2015 but
can't submit them until after October 1,
2015?
2. What is CMS guidance for a claim
with a date of service on or after
October 1, 2015 submitted with the
ICD-9 code set?
*See
http://www.cms.gov/ICD10/Downloads/ICD-10MythsandFacts.pdf
*See
http://www.cms.gov/Enforcement/Downloads/HIPAANonPrivacyComplaintForm.pdf
To be compliant with HIPAA Transactions and Code Sets, any claim received for
dates of service/discharge after October 1, 2015 should be rejected and returned to
the claim submitter. Refer to the MLN Article MM7492 for further guidance to
providers for claims that span the periods where ICD-9 and ICD-10 codes may
both be applicable.
*See
MLN Article
https://www.cms.gov/MLNMattersArticles/downloads/MM7492.pdf
3. What are billing requirements for
facility claims that cross the Oct 1,
2015 date?
• Inpatient facilities
MLN Article
https://www.cms.gov/MLNMattersArticles/downloads/MM7492.pdf
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• Home health facilities
• Outpatient facilities
4. What is CMS guidance when there is a
primary payer and a supplemental
AND one of the payers is ready and
receiving ICD-10 but the other is not?
5. What happens if one insurance
company interprets an ICD-10 code
differently than another insurance
company for the same exact diagnosis
or procedure? (this could apply if the
primary/secondary explanation of
payments show different results)
6. Using the 5010 electronic 837
transaction, will providers need to test
claims with ICD-10 data with payers
prior to the deadline?
1. How should providers globally
approach ICD-10 implementation?
Preparing for
ICD-10
What should providers do now to
prepare?
Comments /Additional Resources
CMS has given limited guidance except to communicate with your payers.
http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10Communicating
withYourPayers.pdf
A contingency plan should be developed in case one or more payers are not ready
on the compliance date. Such a plan is critical since submission of ICD-9 codes
after the implementation date will not be HIPAA compliant and could result
in claim rejection as well as putting providers and payers at risk of penalties for
violating HIPAA.
Claims processing rules are designed to support a payer’s business requirements,
no differently than in ICD-9 today. These can include member benefits, coverage
policies as well as clinical policies. ICD-10 codes can be used to execute these
requirements within the health plan system, but are specific to that health plan.
There may be variances in claims processing based on these factors.
Health plans provide access to policy information on their websites where you can
find additional information.
Providers should first create a Project Plan that:
• conducts a ICD Data Flow Analysis, which creates an inventory of your
current systems and processes that use ICD-9,
• establishes a budget for the implementation,
• coordinates with their vendors, payers, billing service and/or clearinghouses,
• conducts a work flow analysis and needed changes,
• identifies specific needs for staff training, and
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•
Comments /Additional Resources
tests revised processes with your vendors and payers.
No one-size-fits-all approach will meet the needs of all Providers.
Implementation strategies will vary by:
• type of provider (facilities vs. ambulatory settings)
• size of the provider organization
• level of staff knowledge
• degree of “automation” (use of electronic systems)
For details on Project Planning for ICD-10, the CMS link provides
Implementation Guides, Timelines, and Checklists for Small/Medium Practices,
Large Practices and Small Hospitals.
http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html
*See
AMA:
http://www.ama-assn.org/ama/pub/physician-resources/solutions-managingyour-practice/coding-billing-insurance/hipaahealth-insurance-portabilityaccountability-act/transaction-code-set-standards/icd10-code-set.page
AHIMA:
http://www.ahima.org/icd10/implementing.aspx
2. How will the transition to ICD-10
impact my staffing structure?
Staffing needs and skills training will vary based on specifics of the
implementation strategy. An ICD Data Flow Analysis will help determine which
departments and their staff, and in what manner and degree, will be impacted, by
ICD-10 implementation.
In brief:
• Practitioners will need to provide detailed and extensive clinical documentation
to enable accurate and complete ICD-10 code selection.
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3. How do we estimate the amount of time
we’ll need to transition to ICD-10 and
the operating costs we will incur?
4. Are there training
requirements/expectations (intensity,
amount of training time, etc.) for which
providers and coders should be prepared
for? What are some good training
resources/tools that are available?
5. What is the estimated impact of the
Transition to ICD-10 on Medicare
Inpatient Hospital Payments
6. Are there recommended metrics that
should be considered and possibly
developed to help measure pre/post
ICD-10 implementation
performance/impact?
Comments /Additional Resources
• Operations staff will need to adapt systems, policies and procedures to reflect the
changes in operational steps.
• Operations staff will also need to assess the requirements of external parties,
including health plans/payers, and identify information system changes to be
made. The organization also must make sufficient resources available to test
those systems and closely monitor results from health plans/payers, to ensure that
services are accurately adjudicated.
See the Implementation Guide associated with your type/size organization, then go
to Implementation Timeline section in that document.
See
http://www.cms.gov/Medicare/Coding/ICD10/ICD10ImplementationTimelines.html
See the Implementation Guide associated with your type/size organization, then go
to Assess Training Needs section in that document.
See
http://www.cms.gov/Medicare/Coding/ICD10/ICD10ImplementationTimelines.html
See:
http://www.onehealthport.com/sites/default/files/pdf/millimanicd-10-impactprovider.pdf
See WEDI white paper on ICD10 Critical Metrics for each of the following
entities:
• Hospitals
• Practitioners (including individual and group providers)
http://www.wedi.org/docs/resources/wedi_impact_assessment_swg_white_paper_i
cd10_metrics_revised_111412-pdf.pdf?Status=Master
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