What is ICD-10-CM?
ICD-10-CM is a new diagnosis classification system that will be used by health care providers to code each diagnosis a human being may be given. The code allows every medical professional in the U.S. and many other parts of the world to understand the diagnosis the same way. Health insurance organizations, like Samaritan Health Plan Operations (SHPO), receive and pay claims from health care providers based on these codes.
The new system was developed by the Centers for Disease Control and Prevention (CDC) for use in all U.S. health care settings. It will replace the existing diagnosis code set, ICD-9-CM .The U.S. Department of Health and Human Services (HHS) has mandated that all HIPAA-covered entities must implement ICD-10-CM for use in standard electronic transactions (including but not limited to claims) for dates of service that occur on or after Oct. 1, 2015.
What is ICD-10-PCS?
ICD-10-PCS is the Procedure Classification System developed by the Centers for Medicare and Medicaid Services (CMS) for hospital inpatient settings only. It will replace ICD-9-CM as the code set for reporting hospital inpatient procedures in HIPAA standard electronic transactions for dates of service on or after Oct. 1, 2015.
For more information, visit the CMS ICD-10 website.
How is ICD-10 different from ICD-9?
ICD-10 is more than just a revision of ICD-9. First, there are many, many more codes. ICD-9 contains approximately 13,000 codes. ICD-10 contains approximately 68,000 available codes. Second, the structure of the codes is greatly expanded with additional alpha numeric characters. This will allow the reporting of medical data with much greater specificity, which in turn is expected to improve the efficiency of health care reimbursement and reduce charges of fraud and abuse.
When is the ICD-10 transition taking place?
On Oct. 1, 2015, SHPO will adopt the CMS Claims Processing Guidelines for ICD-10.
Since the World Health Organization (WHO) is already working on ICD-11, can providers wait and more directly into ICD-11?
No. The transition into the ICD-10 is mandated by the government. For more information, visit http://who.int/classifications/icd/en/.
What is SHPO doing to prepare for the ICD-10 transition?
SHPO has a dedicated team working on the ICD-10 transition. They have:
- Completed an assessment to identify the impacts the ICD-10 transition will have on each area of the organization.
- Developed a roadmap to define SHPO’s implementation plan, which includes a timeline to complete business requirements, system design and development, internal and external testing, medical policy updates, communication initiatives, and training.
- Reviewed and are addressing the technical upgrades needed for a number of key systems impacted by ICD-10.
Will SHPO accept claims with ICD-9 codes after Oct. 1, 2015?
ICD-9 codes will only be accepted if the service or discharge occurred prior to Oct. 1, 2015. If the date of service or discharge occurred on or after Oct. 1, 2015, the claim must contain ICD-10 diagnosis codes.
Does SHPO expect any delays in claim adjudication with the implementation of ICD-10?
Plans are in place to mitigate any potential delays that might occur in payment processing as a result of the transition to ICD-10. Business continuity for our providers and the prompt processing of claims is of the utmost importance for SHPO.
How does the implementation of ICD-10 impact providers who still file paper claims?
The implementation of ICD-10 does not impact how a claim is submitted. The method used when submitting a claim does not change the code set used on the claim.
What happens if a provider does not switch to ICD-10?
Claims that do not contain ICD-10 diagnosis and inpatient procedure codes for services provided on or after the implementation date will be returned. They will be considered non-HIPAA compliant.
Will SHPO accept ICD-9 and ICD-10 codes on the same claim?
No. ICD-9 and ICD-10 codes will need to be submitted on separate claims. This is mandated by CMS guidelines.
Who can providers contact to test claims processing with sample ICD-10 claims?
Providers should contact Rebecca Smith, SHPO Claims Supervisor at 541-768-4123.
How will SHPO handle authorization requests that occur on or after the ICD-10 compliance date?
SHPO will accept diagnosis codes on authorization requests as follows:
- For dates of service before Oct. 1, 2015, providers must submit an ICD-9 code.
- For dates of service on Oct. 1, 2015 and after, providers must submit an ICD-10 code.
- On July 1, 2015, SHPO will begin accepting ICD-10 authorization requests for dates of service on or after Oct. 1, 2015.
Are there any resources you recommend to help providers prepare for ICD-10?
Centers for Medicare & Medicaid Services (CMS) has developed an ICD-10 implementation guide that can be helpful for clinics of all sizes. The guide also includes links to many other useful tools and resources to help with the ICD-10 transition.
Other useful provider resources include:
ICD-10 – Checklists and Implementation Toolkits (AHIMA)
Oregon Health Plan ICD-10