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ICD-10 FAQ

Claim Submission

Q1.  Who is affected by the transition to ICD-10? If I don’t deal with Medicare claims, will I have to transition?

A1.  Everyone covered by HIPAA must transition to ICD-10. This includes providers and payers who do not deal with Medicare claims.

 

Q2. When will Wellmark begin accepting ICD-10 codes on our claims?

A2. On October 1, 2014, Wellmark will accept ICD- 10 codes on claims for services provided on or after October 1, 2014. ICD-10 codes cannot be used to bill services provided before that date.

 

Q3. Will there be a transition or grace period during which Wellmark will accept either an ICD-9 or ICD‑10 code on our claims regardless of the date of service?

A3. Per the mandate, claims with service dates on or after October 1, 2014, must process using ICD-10 codes, while service dates prior to October 1, 2014, must process using ICD-9 codes. Wellmark will deny claims submitted with inappropriate codes as determined by the date of service.

 

Q4. How should we file a claim that includes services before and after October 1, 2014?

A4. Claims cannot be submitted with a mix of ICD-9 and ICD-10 codes. Claims submitted with both will be rejected. To determine how to file services, refer to the tables in CMS ruling (CR #7492). Wellmark will communicate any deviations from the CMS guidance in future Blue Ink newsletters or on our ICD‑10 website page.

 

Q5. When is the last date Wellmark will accept ICD‑9 codes?

A5. For most Wellmark members, you have 365 days from the date of service to file a claim for the first time. This means that services provided on September 30, 2014, must be filed by September 30, 2015, which will be the last date a new claim can be submitted with an ICD-9 code. Wellmark’s timely filing guideline includes a few exceptions, including Medicare supplement and BlueCard® claims (for members whose coverage is with a Blue Plan in another state). See the Claims filing section of our Wellmark Provider Guide for specific timely filing information.

 

Q6. Will both electronic and paper claims require ICD-10 coding?

A6. All claims need to be compliant.

 

Q7. If we transmit electronic claims, do we need to make any interface or other technical adjustments to assure complete and accurate transmissions?

A7. All electronic claims need to be in the HIPAA X12 Version 5010 format, which accommodates the ICD-10 code structure. The compliance deadline for HIPAA 5010 compliance was January 1, 2012.

 

Q8. Will there be a crosswalk document available?

A8. A crosswalk document will not be available because Wellmark is converting to a system based on ICD-10 codes; we are not using a mapping system to crosswalk codes.

 

Q9. Will rebills have to be recoded with ICD-10 codes?

A9. Rebilling a claim would not change which coding system is utilized since the rebilled claim would not have a change to the date of service. The date of service or discharge is the determining factor to which ICD coding system is utilized in processing a claim.

 

Q10. Codes change every year, so why is the transition to ICD-10 any different from the annual code changes?

A10. ICD-10 codes are different from ICD-9 codes and have a completely different structure. Currently, ICD-9 codes are mostly numeric and have 3 to 5 digits. ICD-10 codes are alphanumeric and contain 3 to 7 characters. ICD-10 is more robust and descriptive with “one-to-many” matches in some instances. ICD-10 has significantly more codes due to more granular specificity. Like ICD-9 codes, ICD-10 codes will be updated every year.

 

Q11. Are there any changes planned on how to submit claims containing ICD-9 and/or ICD-10 codes?

A11. There are no changes to the claim submission process.  Submitters will continue to use the existing processes for submitting batches of claims to Wellmark.  837 claim batches can contain both ICD-9 and ICD-10 claims.

 

Claims Reimbursement

Q1. Will Wellmark renegotiate provider contracts that have diagnosis-based payment provisions?

A1. Wellmark is required to provide a 120-day notice prior to the effective date of any provider agreement change. At this point, we are evaluating the effect of the ICD-10 changes and will communicate information on this topic in the future.

 

Q2. Will DRG groupers (inpatient and outpatient facility) continue to be based on ICD-9 codes after the adoption of ICD-10 codes?

A2. Our groupers will be both ICD-9 and ICD- 10 compliant so that Wellmark can process services correctly based on the date of service.

 

Q3. If ICD-10 codes are used, will the payer give the member a copy of the new grouper logic?

A3. Wellmark uses 3M grouping software which is proprietary.

 

Q4. How will you handle payment for diagnosis based reimbursement?

A4. Reimbursement for dates of service through September 30, 2014, will be based on ICD-9 diagnosis and procedure codes. Reimbursement for dates of service on and after October 1, 2014, will be based on ICD‑10 codes.

 

Q5.  Will Wellmark use the CMS’s ICD-10-CM/PCS Reimbursement Mappings for a reimbursement crosswalk?

A5.  No, Wellmark is not using CMS’s crosswalk.  In fact, Wellmark will not use any crosswalk for reimbursement purposes.  We will use 3M’s grouper software that will directly accept ICD-10 to determine DRGs for reimbursement.

 

Transition

Q1. Where are you in your implementation/conversion cycle?

A1. We have completed user acceptance testing with our claims receipt, processing, and payment systems and promoted ICD-10 changes into production in October 2013. We are preparing for External Testing starting in April and are continuing to complete change to our downstream systems (data warehouse, web based applications, etc.).

 

Q2. Do you intend to change medical-necessity requirements because of the more specific codes that will be available?

A2. No, Wellmark is not changing the intent of any of our medical policies due to ICD-10.

 

Q3. Are you using any crosswalks in your medical policies?
A3. No, we have carefully evaluated each system business rule to add the equivalent ICD-10 codes within our systems to ensure each medical policy continues as currently defined.  We are not using any crosswalks within our system.

 

Q4. Because there will be a period where you will be simultaneously processing ICD-9 and ICD‑10 claims that will have very different IT processing requirements given the differences in amount of data, complexity, etc., what are your plans to manage potential problems related to network connectivity processing time and overall integration?

A4. The Wellmark systems and processes will be updated to handle the ICD-9 claims run out and ICD‑10 claims using technology to sufficiently handle both ICD-9 and ICD-10 processing.  Significant volume testing is planned to ensure no interruption to our processing capacity.

 

Q5.  Where are you in your implementation/conversion cycle?

A5. We are currently completing user acceptance testing with our claims receipt, processing, and payment systems.  These changes are scheduled to move to production in October 2013.

 

Q6. What system(s) of yours will need to be updated in order to be ICD-10 compliant?

A6. Claims processing, payment reporting and downstream systems will be updated.

 

Q7. Will you be required to fully upgrade your system(s) or will you only be installing a fix or patch?

A7. Wellmark is fully upgrading its systems for ICD-10.

 

Q8. How will your organization communicate about the ICD-10 transition?
A8. Email, Frequently Asked Questions will be posted on www.wellmark.com, ICD-10 articles will be published within our Blue Ink

 

Q9. Do you anticipate any delays in payments to result from the switch to ICD-10?
A9. We do not anticipate any delays in payments for claims that are submitted correctly.

 

Q10. How does your organization plan to handle anticipated ICD-9 or ICD-10 reimbursement/adjudication delays?

A10. Wellmark is currently in process of identifying and developing mitigation plans for any potential reimbursement/adjudication delays.

 

Q11.  Do you require ICD-9 or ICD-10 coding on pre service requests?  If yes, what will happen if the codes submitted do not match the codes on the pre service request exactly, will the claims deny?

A11.  We do require diagnosis codes to be submitted on prior authorization requests.  We will announce at a later date more detail on when to begin submitting ICD-10 codes within pre service requests. 

 

Q12.  How are CPT and HCPCS codes affected?  
A12.  No, current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes are not a part of this transition. 

 

Q13.  Will Wellmark use ICD-10 PCS coding for outpatient services?

A13.  No, we will use ICD-10 PCS (surgical procedure codes) only for inpatient claims.  Please continue to use CPT® and/or HCPCS for outpatient services.

 

Q14. What is Wellmark’s contingency plan for ICD-10?

A14. We will follow any updates by CMS by adjusting our guidelines appropriately.

 

Q15. How would Wellmark recommend home care claims be billed where the 60 day certification period spans Oct. 1, 2014?

A15. Each claim submitted for home care needs to use the correct diagnosis codes based on the date of service. Claims with FROM and THROUGH dates spanning the ICD-10 implementation date (Oct. 1, 2014) cannot be billed on one claim. Since treatment plans are not directly tied to the submission of the claim, you can determine your own ICD-10 codes and submit the claim without requesting new orders.

Testing Approach

Q1. Will your organization allow providers to test directly with you? If yes, please explain how the process works for providers.

A1. Yes – Claim files (837) containing claims with ICD-10 codes will be allowed to be submitted to our test environment within our clearinghouse.  The claims will be processed.  For those providers set up for our test 835s, electronic remittance advice will be returned through our clearinghouse based on data within our test environment.

 

Q2. Will Wellmark support end to end testing?

A2. We will support end to end testing as defined by receipt of the 837 claim containing ICD-10 codes through adjudication and transmission of an 835 remittance advice.

 

Q3. When will Wellmark be ready to accept test claims containing ICD-10 codes?

A3. Wellmark plans to target key hospitals to test with us first quarter 2014. We will contact those providers in advance.  As of April 1, all submitters will be encouraged to submit test claims with ICD-10 codes through our Clearinghouse and receive 835 remittance advice based on the ICD-10 codes 

 

Q4. What transactions will your organization want to test for ICD-10?

A4.  837 Claims; 835 Electronic Remittance Advice

 

Q5. Will Wellmark share its testing results?

A5. Wellmark is currently evaluating our approach and will communicate information in the future.

 

Q6.  What requirements are needed to test with Wellmark?

A6.  We will accept HIPAA 5010 837 claims containing ICD-10 codes in our test environment.  These claims will be processed using ICD-10 edits and reimbursements will be calculated with ICD-10 grouper software.  In order to receive reimbursement information, you must be registered with Wellmark to receive test 835 responses.  No paper reports will be mailed from our test environment.

 

Q7. Will providers be able to test both ICD-9 and ICD-10 claims through the test environment?

A7.  Yes!  We will announce a test process that will allow you to submit claims with ICD-9 codes and then separate claims with ICD-10 codes.  This will allow you to compare your claim results for dual coded claims.  Claims must contain valid Wellmark member and provider information as well as valid ICD-9 or ICD-10 codes to process through our test environment.

 

Q8. Will end to end testing include syntax testing?

A8. Yes, HIPAA X12 Version 5010 requirements will be evaluated during testing and any invalid claims will be rejected.

 

Q9.  Will I receive an 835 for every claim submitted?

A9.  Claims must automatically adjudicate (first pass) for an 835 to be created.  We will not work claims in the test environment.  Therefore, if your claim suspends, you will not see it in your 835 remittance advice response.

 

Q10.  Can I work directly with Wellmark for testing, or do I need to work through my Clearinghouse or Vendor?

A10.  If you use a clearinghouse or billing service to submit medical claims to Wellmark, you will need to work with them to coordinate all of your testing.  Your Clearinghouse and/or Vendor will need to be able to send 837 claim records to our test environment and receive 835 remittance advice from our test environment.

 

Q11. If my vendor has already tested with Wellmark, do I need to also test with Wellmark?

A11. Yes! The ability to transmit ICD-10 data was tested under 5010. The transition to ICD-10 is much larger than changing how you send data. The codes used by your medical coders determine benefits, medical policy and payment. By testing with Wellmark, you are able to confirm your coding team has a solid understanding of ICD-10 and your claims will adjudicate as expected.

 

Q12. What types of claims will you accept during ICD-10 testing?

A12. We will test with institutional, outpatient and professional claims.

 

Q13. What is the turnaround time to receive reports once the file is transmitted?

A13. To Be Determined

 

Q14. Will we be receiving the same reports we currently receive in production?

A14. Yes, you will receive the .TXN, .Z16, .999, reports for both ICD-9 and ICD-10.

 

Q15. Do we need to inform someone when we are ready to transmit a test file, and if so, what contact name and number?

A15. No, our test system is automated to receive and process test files.

 

Q16. If I have questions specific to the ICD-10 transition, how do I contact Wellmark?

A16. Please send all inquiries to our ICD-10 e-mail box: ICD-10Testing@wellmark.com. Our customer and provider service team members are not prepared to assist with ICD-10 testing and transition questions.



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