ICD-10 End-to-End Testing Checklist
Institutional Providers
Thank you for volunteering to conduct ICD-10 testing with Palmetto GBA. Your partnership
puts us on course for successful implementation of this important initiative by October 1, 2015.
Below are testing suggestions and tips we would like to share with you as you continue to test:
Preparing For Testing:
 Testing will be conducted April 27, 2015 through May 1, 2015.
 Test claim files must be sent to the Medicare Administrative Contractor (MAC) the same
way you send claims today.
 Test claim files must use the Submitter ID (Trading Partner ID) that was provided to the
MACs during the volunteer registration.
 Test claim files must be marked as “Test” by using indicator “T” in the ISA 15 field.
 Test claim volume is limited to a total of 50 claims for the entire testing week with no more
than 3 test files. If more than your allotted 50 claims are submitted for the week, they may
not be processed.
 Remittance Advices (RAs) will be produced daily as claims complete processing; please be
sure to check them daily to identify any discrepancies that have occurred and contact your
MAC accordingly. Please note: Certain types of claims could take up to two weeks.
 The ERA files will be marked as “Test” files in the ISA 15 field with a “T.”
 Be sure the MAC has a complete list of all of the Health Insurance Claim Numbers (HICNs)
that will be used to test. Do not submit claims with any other HICNs.
 Ensure the MAC has a complete list of the NPIs and PTANs that you will use to test because
the MACs must set up their files to accept them.
 If you use NPIs, PTANs, or HICNs that were not submitted to the MAC on the volunteer
form, your claims will not be processed.
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Creating Test Claims:
 IMPORTANT: Claims that you would normally submit should be used to start building your
test cases. Include procedure codes you commonly bill, along with the ICD-10 diagnosis that
most closely represents the diagnosis you would submit for that type of claim. Refer to the
Future Local Coverage Determinations for questions on the covered diagnosis codes for a
particular policy.
 Ensure your claim has complete information so it is not rejected for anything not related to
ICD-10. Remember the purpose of your testing is to help you prepare for ICD-10. The
Medicare claims processing system used to process test claims is the same one you use today,
with the exception of the ICD-10 logic. If your test claims do not meet all of the existing
coding guidelines for submitting a proper claim, the claim will reject and not show on your
RA. Most test claim errors in the previous end-to-end testing week were not ICD-10 related.
 Some general claim criteria are provided below:
1. A discharge status is required on all type of bills.
2. ICD-10 Procedure codes are only billed on inpatient claims.
3. Type of bills 11x, 12x, 18x, 21x, 22x, 32x, 41x, 81x, and 82x must have an admission
date.
4. Type of bills 11x, 12x, 18x 21x, and 22x must have a type of admission.
5. If applicable, include the attending, ordering, or operating physician NPIs, as well as
facility NPIs.
6. Ensure that the days reported match the statement covers dates.
7. Verify that the ICD-10 procedure code date submitted is within the statement
dates/admit dates.
8. Type of bill 13x should include a patient reason for visit.
9. Do not submit duplicate diagnosis codes on the same claim.
10. Do not submit claims with dates of service after 12/31/2015.
 Do not submit a date of service earlier than October 1, 2015 for test claims that contain ICD10 codes.
 Do not bill ICD-9 and ICD-10 codes on the same claim.
 Ensure test claims contain both the National Provider Identifiers (NPIs) and corresponding
Provider Transaction Access Numbers (PTANs) that you told your MAC you would use for
testing.
 Ensure the rendering provider corresponds with the correct billing provider submitted during
the volunteer process.
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 Ensure test claims contain the Health Insurance Claim Number (HICNs) that you told your
MAC you would test with and ensure they are active, valid HICNs (not for deceased
patients).
 Ensure the patient’s name matches the HICN.
 Submit a variety of claims that best represents your business and utilizes the various code
types (i.e. procedure codes, principal diagnosis, admitting diagnosis, patient reason for visit,
and external cause of injury).
 Don’t forget the “0” or “9” qualifier code to identify ICD-9 and ICD-10 claims.
 Consider submitting multiple detail lines of service on each claim.
 Submit procedure codes and ICD-10 diagnoses codes that have specific medical necessity
requirements as outlined in Local Contractor Determinations (LCDs), National Coverage
Determinations (NCDs), or other local coverage policies your MAC may have in place.
 Consider choosing patients who have different billing situations (i.e. Medicare as the
secondary payer (MSP), Coordination of Benefits (COB), Medicaid crossover claim, hospice,
and Health Maintenance Organization (HMO)) in addition to traditional Medicare.
 Avoid submitting claims for the same patient for the same date of service AND procedure
code. The claim will deny as a duplicate.
 Do not use the same diagnosis code as your principal/primary diagnosis code for each test
claim.
 Ensure claims for date of service October 1, 2015 and after are billed with an ICD-10 code
and Diagnosis Qualifier/Indicator 0. Dates of service September 30, 2015 and prior must be
billed with an ICD-9 code and Diagnosis Qualifier/Indicator 9.
 Consider submitting the maximum number of ICD-10 diagnosis codes per claim. ICD-10CM codes can have from 3 to 7 characters. You must report all of the characters. For
instance, if the ICD-10-CM code is 7 characters long, then you must report all 7 characters.
 If you tested in a previous end-to-end testing week, ensure your claims for this testing week
do not duplicate previously processed claims. It is acceptable to resubmit corrected claims
from the previous testing week that were return to provider (RTP).
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 Home Health
- Revenue code 0023 must be reported with appropriate Health Insurance Prospective
Payment System (HIPPS) code.
- Must have an attending physician.
- Treatment authorization code must be present.
- Value code 61 must be billed with Core-Based Statistical Area (CBSA) code of the
service location.
- Final claims (other than LUPAs) must also have a matching RAP.
 Skilled Nursing Facility (SNF)/Swing bed
- A 3-day inpatient qualifying stay needs to be on file.
- Revenue code must be 0022 with an appropriate HIPPS code.
- Need room and board revenue code (units on both revenue code 0022 and room and
board must match.
- A HIPPS code of anything other than AAAxx will need at least one occurrence code 50.
 Hospice
- Claims ONLY should be submitted. NOEs will be entered by the MAC, since hospices
will not have DDE access.
- Value code should be 61 with CBSA code of home service location with revenue code
0651 or 0652.
- Value code should be G8 for location of inpatient services with revenue code 0655 or
0656.
 End Stage Renal Disease (ESRD)
- Only one condition code, 70-76 can be present on the claim.
- Value codes must be A8, A9 and D5 with appropriate amounts.
- Revenue codes must be 821, 831, 841 or 851.
- Healthcare Common Procedure Coding System (HCPCS) 90999 must be billed with
revenue code 82x and appropriate G-modifier (G1-G6).
- Primary diagnosis code must be a Chronic Renal Failure diagnosis code.
 Acute Care Inpatient (IPPS)
- Revenue code must be included for room and board.
- Value codes must be 80 (covered days), 81 (non-covered days), 82 (coinsurance), 83 (life
time reserves), 09 (1st year coinsurance), 11 (2nd year coinsurance), 08 (1st year lifetime
reserve days), or 10 (2nd year lifetime reserves).
- Include a Present on Admission (POA) indicator and remember that a code exempt from
POA should not have a POA indicator submitted. The 2015 ICD-10-CM POA Exempt
list can be found at http://www.cms.gov/Medicare/coding/ICD10/2015-ICD-10-CM-andGEMS.html (the last Downloads document).
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 Inpatient Rehab Facility
- The same requirements as acute care inpatient above apply except:
 Revenue code will be 0024 with valid HIPPS
 Federally Qualified Health Clinic (FQHC)
- Encounter/visits must be billed under revenue code 052x.
- Telehealth must be billed with revenue code 0780 and HCPCS Q3014.
- Mental health treatment should be billed with revenue code 0900.
- Diabetes self-management training and medical nutrition therapy should be billed with
revenue code 052x with procedure codes G0108 or 97802.
 Ambulance
- Type of bill should be 13x, 22x, 23x, and 85x.
- Revenue code should be 054x.
- Bill with the appropriate ambulance HCPCS and units.
- Make sure there is an appropriate origin and destination modifier.
- Submit value code AO with the zip code of the pickup location.
 Therapy Claims
- Physical therapy services require revenue code 42x, GP modifier, occurrence code 11, 29
and 35.
- Occupational therapy services require revenue code 43x, the GO modifier, occurrence
code 11, 17, and 44.
- SLP services require revenue code 44x, GN modifier, occurrence code 11, 30, and 45.
How to Avoid Return to Provider Claims
Claims which have errors and return to provider (RTP) will not produce a remittance advice.
Below are helpful hints to avoid these claims during ICD-10 testing:
1. The spelling of the beneficiary’s name and the HICN must match Medicare’s master
eligibility record.
2. The number of days represented by the “from” and “through” dates on the claim must be
counted correctly. If the dates are not the same on the inpatient hospital or SNF claims, the
number of days represented must equal the sum of the covered days plus the non-covered
days unless the patient status is 30, in which one additional day is used for the calculation.
3. External causes of injury are no longer reported with E-codes in ICD-10. Only diagnosis
codes V00.01A-Y99.9 are accepted on ICD-10 claims.
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4. The admitting diagnosis field for the date of service must be a valid diagnosis code for the
date of service.
5. Ensure that the admission date equals the statement to date on a Prospective Payment System
(PPS) claim.
6. Check that claims billed with an ICD-10 diagnosis code do not have statement “from” and
“to” dates prior to October 1, 2015. Any date prior to October 1, 2015 must be billed with an
ICD-9 diagnosis code.
7. The covered days on a claim should be numeric or blank.
8. Bill with valid procedure codes.
9. Sometimes claims are rejected because there is a cross referenced claim and the type of bill
needs to be adjusted or cancelled. Avoid these situations by minimizing adjustments bill
types (117) or sequential billing that may cause claims to RTP if prior claims are not
finalized history.
10. The “from” date is after the “admit” date and the system is looking for another claim in order
to be processed. For testing purposes, make sure the admit date is equal to the “from” date
on inpatient claims. Once again, all claims should be original bill and make sure the
admission and from dates are valid.
After Submitting Test Claims:
As Remittance Advices (RAs) are produced, check them daily to identify any discrepancies that
have occurred and contact your MAC accordingly.
Additional Resources:
Centers for Medicare & Medicaid Services Resources:
CMS has developed timeline resources, checklists, and provides various resources to help the
health care industry transition to ICD-10 by the October 1, 2015, deadline.
 CMS ICD-10
 ICD-10 Final Rule
 Latest News
 Provider Resources
Frequently Asked Questions:
A listing of ICD-10 frequently asked questions is available on the
http://www.palmettogba.com/ICD-10/FAQ of the Palmetto GBA website.
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MLN Matters Articles:

MM7492: Medicare Fee-For-Service (FFS) Claims Processing Guidance for
Implementing ICD-10

MM8465: International Classification of Diseases, 10th Revision (ICD-10) Testing with
Providers through the Common Edits and Enhancements Module (CEM) and Common
Electronic Data Interchange (CEDI)

SE1239: Updated ICD-10 Implementation Information

SE1240: Partial Code Freeze Prior to ICD-10 Implementation

SE1409: Medicare Fee-For-Service (FFS) International Classification of Diseases, 10th
Edition (ICD-10) Testing Approach
MLN Matters Fact Sheets:


ICD-10-CM/PCS: The Next Generation of Coding
ICD-10-CM/PCS: Myths and Facts
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