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The questions and answers here were compiled from providers prior to and after the introduction of the International Classification of Diseases, 10th Revision (ICD-10) codes on Oct. 1, 2015. (For answers regarding specific claims, use the Check a Claim tool and select “Inquire or Submit Documents on this Claim” from the drop-down menu.)
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Q1. What are the ICD-10 final rule compliance requirements?
A1. The ICD-10 final rule mandates the use of two code sets by Oct. 1, 2015: ICD-10-CM (clinical modifications) for diagnostic conditions and ICD-10-PCS (procedure code system) for inpatient procedure codes. The ICD-10-CM have replaced the ICD-9-CM Volumes 1 and 2 for diagnosis codes. The ICD-10-PCS have replaced ICD-9 Volume 3 for inpatient procedure codes.
Q2. Codes change every year, so why was the transition to ICD-10 any different from the annual code changes?
A2. ICD-10 codes are different from ICD-9 codes and have a completely different structure. The ICD-9 codes are mostly numeric and have three to five digits. ICD-10 codes are alphanumeric and contain three to seven characters. ICD-10 is more descriptive and has significantly more codes due to more granular specificity. Like ICD-9 codes, ICD-10 codes will be updated each year.
Q3. Is a crosswalk document available?
A3. A crosswalk document is not available, because Wellmark is converting to a system based on ICD-10 codes; we are not using a mapping system to crosswalk codes.
Q4. Some ICD-9 codes were removed from the provider guides. Why were the codes removed and not replaced by ICD-10 codes?
A4. Wellmark does not offer coding advice on claims. It is the responsibility of the provider to submit the appropriate code(s) for the services rendered. ICD-10 offers additional specificity to the current ICD-9 claims reporting process. Due to the increased volume of ICD-10 codes available, Wellmark has made the decision to remove certain codes but retain some coding descriptions.
Q5. Will Wellmark add ICD-10 codes to the provider guides?
A5. Wellmark does not offer coding advice on claims; however, any request to add ICD-10 codes to the provider guides will be reviewed to determine the volume of translation to ICD-10.
Q6. What if my claim denies for an invalid code? How do I know which code to use?
A6. Wellmark does not offer coding advice on claims. Check out the “Learn More” section of the ICD-10 page for links to coding resources.
Q7. How do I know if the ICD-10 code I’m using is valid?
A7. Use the coding guides and other resources in the “Learn More” section of the ICD-10 page.
Q8. Where can I find coding resources?
A8. Check out the “Learn More” section of the ICD-10 page for links to coding resources.
Q9. Are all CPT® and HCPCS codes affected?
A9. No. Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes are not a part of the ICD-10 transition.
Q10. A procedure modifier indicates a procedure on the ‘left side’ or ‘right side.’ Which ICD-10 code do I use?
A10. If a left or right procedure modifier is used, the ICD-10 code must match the left or right side.
Q11. Is Wellmark using ICD-10 PCS coding for outpatient services?
A11. No. Wellmark uses the ICD-10 PCS (Procedure Coding System) only for inpatient claims. Please continue to use CPT or HCPCS (Healthcare Common Procedure Coding System) codes for other services.
Q12. Does Wellmark reject unspecified codes?
A12. No. However, unspecified codes may have a negative impact on claim reimbursement. For example, the lack of specificity may impact the DRG (Diagnosis Related Groups) or severity of illness.
Q13. Does Wellmark require additional administrative processes for providers (e.g., more requests for medical records) due to the ICD-10 change?
A13. No. Wellmark has not made any changes to administrative processes in anticipation of ICD-10.
Q14. The Centers for Medicare and Medicaid Services announced some steps to ease the transition to ICD-10, including a contingency for using the wrong ICD-10 code. If I use the wrong ICD-10 code, will my claim be denied by Wellmark?
A14. Wellmark does not deny claims based solely on the specificity of the ICD-10 diagnosis code as long as the provider uses a valid code. However, a valid ICD-10 code is required on all claims beginning Oct. 1, 2015. It is possible a claim could be chosen for review for reasons other than the specificity of the ICD-10 code.
Q15. What do I do if I have a question about a claim?
A15. Use the Check a Claim tool for claim status and details. If you have a question about a specific claim, please submit your inquiry using the Ask and Track a Question tool, which is easily accessible from the drop-down menu in the Check a Claim tool. Please note:
- If you do not have access to the Check a Claim tool or the Ask and Track a Question tool, please contact a designated security coordinator in your organization.
- If your organization is not set up for secure access to Wellmark.com, please register now.
- Please allow at least 30 days for processing of inquiries. Those that require additional research may take longer.
Q16. How do I ensure I’m getting the most up-to-date information from Wellmark regarding ICD-10?
A16. For real-time messages regarding ICD-10, including updates to these Web pages, please register for the Wellmark Information Notification System (WINS).
Q17. Where can I find tips regarding benefits, and submitting electronic and paper claims?
A17. Please visit the ICD-10 Best Practices page.
Q18. Can we still test ICD-10 claims with Wellmark prior to submission?
A18. Wellmark’s electronic claims testing environment is always available to providers who would like to test their claims before submitting them to Wellmark. You may test ICD-10 claims at any time; however, Wellmark no longer provides testing support (e.g., processing suspended claims).
Q1. Is there a transition or grace period during which Wellmark will accept an ICD-9 or ICD-10 code on our claims regardless of the date of service?
A1. Per the mandate, claims with service dates on or after Oct. 1, 2015, must process using ICD-10 codes. Service dates prior to Oct. 1, 2015, must process using ICD-9 codes. Wellmark will deny claims submitted with inappropriate codes as determined by the date of service.
Q2. How do I know if my electronic claim was accepted or rejected?
A2. First, check your TXN report for rejected claims. Next, check the Wellmark .z16 claim confirmation detail report. Once a claim appears as “accepted” on the .z16 report, you can check its status using the Check a Claim tool. Alternatively, you may submit a HIPAA 276 electronic claim status inquiry, after which you will receive a 277 claim status response.
Q3. How should we file a claim that includes services before and after Oct. 1, 2015?
A3. 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, please refer to Wellmark’s ICD Span Billing Guide .
Q4. What if a patient is admitted as an inpatient prior to Oct. 1, 2015 and is discharged on Oct. 1, 2015?
A4. ICD-10 diagnoses procedures are required for discharge dates of Oct. 1, 2015, and after. Note: do not split inpatient claims. If an inpatient claim contains a discharge date of Oct. 1, 2015 or later, the entire claim must be submitted using ICD-10.
Q5. If a patient is admitted prior to Oct. 1, 2015, is it appropriate to first submit one claim, admit through discharge for dates prior to Oct. 1, then re-admit the patient on Oct. 1, bill a second claim and admit through discharge for dates after Oct. 1?
A5. No, please refer to Wellmark’s ICD Span Billing Guide . Inpatient claims should not be split, if the inpatient claim contains a discharge date on or after Oct. 1, 2015, the entire claim must be submitted using ICD-10.
Q6. What is the last date Wellmark will accept ICD-9 codes?
A6. Providers have 180 days from the date of service to file a claim for the first time. For example, if a service was provided on Sept. 30, 2015, you must file the claim by March 30, 2016. In this case, the service occurred before Oct. 1, 2015, so it would be filed with an ICD-9 code.
Q7. Do both electronic and paper claims require ICD-10 coding?
A7. All claims must use ICD-10 coding for dates of service on or after Oct.1, 2015.
Q8. On my electronic claim submission (837), which ICD qualifier/identifier do I use?
A8. With dates of service Oct. 1, 2015, and after, the new ICD-10-CM (diagnosis codes) and ICD-10 PCS (inpatient, institutional principal/other procedure) code qualifiers must be used. Qualifiers are used to indicate the type of ICD code that will follow (ICD-9-CM, ICD-10-CM, ICD-9-PCS or ICD-10-PCS). All ICD-10-CM and ICD-10-PCS qualifiers are three characters in length. With the introduction of ICD-10, Wellmark has seen an increase in claim rejections due to incorrect qualifiers. To ensure your claims are not rejected for this reason, please visit the Best Practices page.
Q9. Which ICD indicator or qualifier do I use on claims for dates of service on or after Oct. 1, 2015?
A9. Use ICD-9 indicators or qualifiers for dates of service prior to Oct. 1, 2015 and ICD-10 indicators or qualifiers for dates of service Oct. 1, 2015, and after. The indicator or qualifier varies depending upon the claim format:
- Paper HCFA 1500 claim form — Use the “9” or “0” (numeric zero) indicator in field 21 to indicate whether you are submitting a claim containing ICD-9 or ICD-10 codes. Use "9" for ICD-9 claims and "0" for ICD-10 claims.
- UB-04 facility claim form — Use the “9” or “0” (numeric zero) indicator in FL 66 to indicate you are submitting a claim containing ICD-9 or ICD-10 codes. Use "9" for ICD-9 claims and "0" for ICD-10 claims.
- Electronic HIPAA ACS X12 837 claim format — Use the appropriate two- or three-character qualifier to indicate you are submitting a claim containing ICD-9 or ICD-10 codes. ICD-9 claims require a two-character qualifier (e.g., BK, BF, etc.). ICD-10 claims require a three-letter qualifier (e.g., ABK, ABF, etc.).
Q10. Which CMS-1500 claim form do I use for dates of service after Oct. 1?
A10. Due to the implementation of ICD-10, the old CMS-1500 form (version 08/05) is no longer compliant. Beginning with dates of service of Oct. 1, 2015, Wellmark only accepts paper claims submitted on the CMS-1500 form dated February 2012 (version 02/12). Claims submitted on any outdated versions of the HCFA form will be returned. To avoid having to determine which form to use, please register to submit claims electronically.
Q11. If we transmit electronic claims, do we need to make any interface or other technical adjustments to ensure complete and accurate transmissions?
A11. 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 Jan. 1, 2012.
Q12. What do I do if I’m having issues submitting my claim electronically?
A12. In this case, do not to revert to paper. Because the same criteria are used for both formats, any claim that is rejected electronically will also be rejected on paper. Submitting paper claims almost always increases processing time. If you are having difficulties submitting electronic claims, please work with your clearinghouse, or contact Wellmark’s Electronic Commerce (EC) Solutions at 800-407-0267.
Q13. Do rebills have to be recoded with ICD-10 codes?
A13. Rebilling a claim does not change which coding system is used, because the rebilled claim would not have a change to the date of service. The date of service or discharge is the determining factor regarding which ICD coding system is used in processing a claim.
Q14. Does Wellmark reject or deny claims for unspecified diagnoses codes?
A14. No. Wellmark has not added any new edits that restrict the use of unspecified codes. However, codes must be considered valid per HIPAA 5010 standards. For example, H43 would be rejected as a non-valid code. H43.00 would be considered valid and accepted for an unspecified diagnosis code.
Q15. Can I submit a claim with a future date of service?
A15. No. Claims with future dates of service are rejected.
Q16. I submitted a claim to Wellmark for services provided to a member of another Blue Cross Blue Shield (BCBS) Plan. The claim is coded correctly, but it is processing or denying inappropriately. What should I do?
A16. Highmark BCBS has identified a system issue that is causing approximately 2,700 Blue Card claims like this to be denied. The error message conveys that the claim was not a covered benefit. Please allow 45 days before submitting a provider inquiry. A fix was introduced on Oct. 14 and claims will begin to be remediated on Nov. 9. Thank you for your patience.
Q17. How does the concept of "laterality" apply to ICD-10?
A17. Laterality refers to the side of the body affected. This new coding convention was added to certain ICD-10 codes to increase specificity. Designated codes for conditions such as fractures, burns, ulcers, and certain neoplasms now require documentation of the side/region of the body where the condition occurs. Since the laterality is included in the diagnosis, please remember that it is not appropriate to bill a right and left diagnosis if there is an accurate bilateral diagnosis. For example you should not bill Z96.651 (presence of right artificial knee joint) with Z96.652 (presence of left artificial knee joint). Rather, the appropriate diagnosis code to bill would be Z96.653 (presence of artificial knee joint, bilateral).
Q18. What do I need to know about "excludes" notes with ICD-10 claims?
A18. ICD-10 has two types of excludes notes — Excludes 1 and Excludes 2. Wellmark implemented an edit based on the Excludes 1 notes concept in January 2016; however, due to a high volume of provider denials and additional information published by the Centers for Disease Control and Prevention (CDC), this edit has been temporarily turned off and claims will be remediated. The CDC recognized that there are circumstances where some conditions included in Excludes 1 notes should be allowed for both conditions to be coded, and thus might be more appropriate for an Excludes 2 note. However, due to the partial code freeze, no changes to excludes notes or revisions to the official coding guidelines can be made until October 1, 2016. In the meantime, please take note of the following differences:
- Excludes 1 — Indicates that the code excluded should never be used with the code where the note is located. (I.e., do not report both codes.)
- Excludes 2 — Indicates the condition excluded is not part of the condition represented by the code, but that a patient may have both conditions at the same time. In this case, both codes may be assigned together. (I.e., both codes can be reported to capture both conditions.)
Q1. Has Wellmark renegotiated provider contracts that have diagnosis-based payment provisions?
A1. The current Wellmark reimbursement models make it unnecessary to change provider contracts for processing ICD-10 claims.
Q2. Are DRG payment groupers (inpatient and outpatient facility) still based on ICD-9 codes?
A2. Our groupers are both ICD-9 and ICD-10 compliant, so that Wellmark can process services correctly based on the date of service.
Q3. How does Wellmark handle payment for diagnosis-based reimbursement?
A3. Reimbursement for dates of service through Sept. 30, 2015, are based on ICD-9 diagnosis and procedure codes. Reimbursement for dates of service on and after Oct. 1, 2015, are based on ICD-10 codes.
Q4. Has Wellmark employed CMS's ICD-10-CM/PCS Reimbursement Mappings for a reimbursement crosswalk?
A4. No. Wellmark is not using the crosswalk provided by the Centers for Medicare & Medicaid Services (CMS). In fact, Wellmark does not use any crosswalk for reimbursement purposes. We use 3M's grouper software that directly accepts ICD-10 to determine DRGs for reimbursement.
Q5. What is advanced payment, and how can I access this if needed?
A5. If Wellmark is unable to process claims within established time limits because of the ICD-10 implementation, an advance payment may be available. An advance payment is a conditional partial payment, which requires repayment. If advance payment becomes necessary, additional information will be distributed at that time. Wellmark does not make advance payments in cases where a provider is unable to submit a valid ICD-10 claim.
Q6. How has ICD-10 impacted rehabilitation claims paid on a per diem basis (DRG 860)?
A6. Under ICD-9, only six primary diagnosis codes for rehabilitative services would result in a payment outcome of DRG (diagnosis related group) 860. Not only are those codes no longer valid, but there are now many more from which to choose. With some exceptions, most of the codes in MDC (major diagnostic category) 23 will result in a payment outcome of DRG 860. They also will require procedure codes found in the F003GKZ to F08H5UZ range, and those in the F08H5YZ to F0FZJZZ range. For more information, securely log in to the 3M Health Information Systems support site and refer to the DRG 860 entry in the Definitions Manual.
Medical Policies and Pre-service Review
Q1. How is the pre-service review process impacted by ICD-10?
A1. Just like all other processes with an Oct. 1, 2015 or later date of service, pre-service review requests require a valid ICD-10 code. Requests entered through the Wellmark Utilization Management (UM) tool include a valid code edit, making it impossible to submit without a valid code. Other methods of submitting requests (e.g., by fax or phone), however, do not include a built-in validation step. When an invalid code is used in these cases, the service will be denied upon receipt of the claim. Please be sure the ICD-10 diagnosis is coded to its highest digit required.
Q2. Has Wellmark changed medical necessity requirements because of the more specific codes?
A2. Our medical policies do not contain ICD codes. This has not changed due to the introduction of ICD-10.
Q3. Do Wellmark's medical policies reflect the new ICD-10 codes?
A3. Our medical policies do not contain ICD codes. This has not changed due to the introduction of ICD-10.
Q4. Has Wellmark employed any crosswalks for the medical policies?
A4. 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.
Q5. Does Wellmark require ICD-9 or ICD-10 coding on pre-service review requests?
A5. Wellmark will only accept ICD-10 codes on pre-service review requests with dates of service Oct. 1, 2015, and after. ICD-9 codes will continue to be required for dates of service prior to that date.
Q6. Since Wellmark requires ICD-10 coding for dates of service after Oct. 1, 2015, what will happen if the codes submitted do not match the codes on the pre-service review request? Will the claims deny?
A6. Wellmark will match the claim to the pre-service review request and process the claim accordingly.