ICD-10 Submission Guidelines Clarification

On May 29, 2015 in Network Notification #18, ICD-10 Submission Guidelines, we communicated in error that we would accept ICD-10 codes comprising upper or lower case characters. We will only accept ICD-10 codes comprising upper case characters. Any claim submitted with ICD-10 codes comprising lower case characters will be denied. Please reference the updated ICD-10 Submission Guidelines and reimbursement policy General Billing and Coding Guidelines, policy number WS 4.17.

ICD-10 Update

In July, CMS announced October 1, 2015 as the new deadline for ICD-10 compliance for providers and payers.  HIPAA- covered entities are also required to continue to use ICD-9 codes through September 30, 2015.

Well Sense Health Plan continues to move forward with its commitment to ICD-10 compliance.

ICD-10 Overview

ICD-10-CM is a diagnosis classification and coding system developed by the Centers for Disease Control and Prevention (CDC) for use in all U.S. healthcare settings. ICD-10-CM (International Classification of Diseases, 10th Revision, and Clinical Modification) will replace the existing diagnosis code set: ICD-9-CM. 

The U.S. Department of Health and Human Services mandated that all HIPAA-covered entities must implement ICD-10-CM for use in standard electronic transactions.

As of October 1, 2015, providers must:

  • Submit outpatient claims with dates of service
  • Submit inpatient claims with dates of discharge
  • Claims submitted for service and discharge dates before October 1, 2015 should be coded using the ICD-9 coding standard

Additional information on ICD-10 is available at the Centers for Medicare & Medicaid Services.

> Submitting Claims

The following ICD-10 General Submission Guidelines align with CMS:

  • Providers must submit ICD-9 codes for Dates of Service (DOS) or discharge prior to 10/01/2015. Claims containing ICD-10 codes for services prior to October 1, 2015, will be denied**. Providers will be required to re-submit these claims with the appropriate ICD-9 code.
    ** Exception: See section for specific billing guidelines on Inpatient Hospital & Other Bill Types Spanning Implementation Period
  • Providers must submit ICD-10 codes for DOS or discharge on or after October 1, 2015. Claims containing ICD-9 codes for DOS on or after October 1, 2015 will be denied. Providers will be required to re-submit these claims with the appropriate ICD-10 code.
  • We will deny all claims that are billed with both ICD-9 and ICD-10 diagnosis codes on the same claim.
  • We will only accept ICD-10 codes composed of upper case characters. We will deny any claim that is submitted with ICD-10 codes composed of lower case characters or a mix of both upper and lower case characters.

View all ICD-10 General Submission Guidelines.

> The Impact to Providers

Implementation of ICD-10 will require considerable business and system changes throughout the healthcare industry. The ICD-10 conversion will significantly impact all segments of the health care industry due to:

  • Increased specificity and numbers of codes, going from approximately 3,800 ICD-9 procedure codes to 87,000 procedure codes
  • Expansion of diagnosis codes from 13,000 (ICD-9) to 68,000 (ICD-10)
  • Changing from five-digit numeric codes (except for E and V) to seven-character alphanumeric codes
  • Codes include designation of laterality (left and right)
  • Chapters, categories, and titles have been restructured
  • Combination diagnosis and symptom codes have been created

> The Benefits

The benefits of the ICD-10 conversion include:

  • Accurate payments for new procedures not currently covered by ICD-9 coding
  • Fewer rejected claims due to more specific, non-ambiguous code designations
  • Improved patient disease management
  • Synchronization of disease monitoring and reporting worldwide

> Additional Resources

American Medical Association (AMA)
AMA ICD-10 Project Planning Template
AMA ICD-10 Checklist

Centers for Medicare & Medicaid Services (CMS) - Click here.

American Health Information Management Association (AHIMA) - Tools for the ICD-10 implementation 

American Academy of Professional Coders (AAPC) - ICD-10 implementation and training information

Healthcare Information and Management Systems Society(HIMSS) - This ICD-10 Playbook page contains information about transitioning to ICD-10.

> Testing

Please contact your Provider Relations Consultant if you have any questions related to ICD-10 testing.