ICD-10 Frequently Asked Questions
Oct. 1, 2015, marks the introduction of the International Classification of Diseases, 10th Revision (ICD-10) codes. All providers and health insurers are affected, as well as any business process or technology that stores, processes or uses medical/diagnosis/procedure codes. The questions and answers here were compiled from providers, including those who are engaged in testing claims submissions through Wellmark.
Q1. What are the ICD-10 final rule compliance requirements?
A1. The ICD-10 final rule mandates the use of two code sets by October 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 will replace the ICD-9-CM Volumes 1 and 2 for diagnosis codes. The ICD-10-PCS will replace ICD-9 Volume 3 for inpatient procedure codes.
Q2. Who is affected by the transition to ICD-10? If I don’t deal with Medicare claims, will I have to transition?
A2. The transition to ICD-10 is required for everyone covered by the Health Insurance Portability Accountability Act (HIPAA) . This includes providers and payers who do not deal with Medicare claims. Please note: the change to ICD-10 does not affect CPT coding for outpatient procedures and physician services.
Q3. Is Wellmark prepared to meet the ICD-10 deadline of October 1, 2015?
Q4. Codes change every year, so why is the transition to ICD-10 any different from the annual code changes?
A4. ICD-10 codes are different from ICD-9 codes and have a completely different structure. Currently, 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.
Q5. Will there be a crosswalk document available?
A5. 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 those codes.
Testing with Wellmark
|Note: Below are some basic questions and answers that pertain to testing. For more detailed information, please visit our ICD-10 Testing Instructions page.
Q1. When can testers submit test claims?
A1. Providers should begin submitting test claims now.
Q2. Who can participate in testing?
A2. Any provider who submits claims electronically may test. This includes users of the PCA-AP Pro 32 software provided by Wellmark’s Electronic Commerce (EC) Solutions department. Testing is not available for paper submitters or through Wellmark’s Create and Submit a Claim tool.
Q3. Is there anything special I should know about the pricing used in ICD-10 testing?
A3. Test claim pricing will be the same as it would be in the regular (“production”) environment. Wellmark updates reimbursement annually on July 1.
Q4. After testing, I noticed test claims missing from my HIPAA 5010 835 electronic remittance advice. What happened to them?
A4. Due to the anticipated volume of ICD-10 testing, Wellmark cannot support the processing of suspended claims in the test environment. Under normal circumstances, a suspended claim would result in an 835 electronic response. This is not possible in the test environment.
Q5. After testing, I noticed a payment difference between the ICD-9 and ICD-10 version of my test claim. Why did this happen?
A5. Please ensure you are comparing claims in the same pricing timeline. Wellmark updates reimbursement on July 1. Also note:
- Professional claims should experience few to no changes (e.g., benefit/medical policy changes).
- The percentage-of-charge claims and per-diem claims should experience few to no changes (e.g., benefit/medical policy changes).
- Enhanced ambulatory patient groupings (EAPG) outpatient facility claims use diagnoses to process medical visits (e.g., emergency department visits). Medical visits constitute about 15 percent of EAPG claims. The weights for medical visits have little variation, so payment impacts should be minimal.
- All patient refined diagnosis related groups (APR-DRG) inpatient facility claims use diagnosis and procedure codes exclusively for payment. Based on Wellmark research, you can expect a 3 percent to 5 percent difference. For more information, please refer to our issue brief regarding inpatient claims.
Q6. Where do I find ICD-10 coding resources?
A6. Wellmark suggest accessing the Centers for Medicare and Medicaid Services (CMS) resources for assistance with ICD-10 coding.
Q1. When will Wellmark begin accepting ICD-10 codes on claims?
A1. On October 1, 2015, Wellmark will accept ICD-10 codes on claims for services provided on or after October 1, 2015. ICD-10 codes cannot be used to bill services provided prior to this date.
Q2. Will there be 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?
A2. Per the mandate, claims with service dates on or after October 1, 2015, must process using ICD-10 codes. Service dates prior to October 1, 2015, must process using ICD-9 codes. Wellmark will deny claims submitted with inappropriate codes as determined by the date of service.
Q3. How should we file a claim that includes services before and after October 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 is the last date Wellmark will accept ICD-9 codes?
A4. For most Wellmark members, you currently have 180 days from the date of service to file a claim for the first time (e.g., a service provided on Sept. 30, 2015, must be filed by March 30, 2016). The service occurred before Oct. 1, 2015, so it would be filed 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), etc. See the Claims Filing section of our Wellmark Provider Guide for specific timely filing information.
Q5. Will both electronic and paper claims require ICD-10 coding?
A5. All claims must use ICD-10 coding.
Q6. If we transmit electronic claims, do we need to make any interface or other technical adjustments to ensure complete and accurate transmissions?
A6. 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.
Q7. Will rebills have to be recoded with ICD-10 codes?
A7. Rebilling a claim would 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.
A8. Will Wellmark reject or deny claims for unspecified diagnoses codes?
Q8. 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.
Q1. Will Wellmark renegotiate 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. Will DRG payment 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. How will Wellmark handle payment for diagnosis-based reimbursement?
A3. Reimbursement for dates of service through Sept. 30, 2015, will be based on ICD-9 diagnosis and procedure codes. Reimbursement for dates of service on and after Oct. 1, 2015, will be based on ICD-10 codes.
Q4. Will Wellmark use the 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 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.
Q1. Will Wellmark change medical necessity requirements because more specific codes will be available?
A1. No. Wellmark is not changing the intent of any of our medical policies due to ICD-10.
Q2. Will Wellmark's medical policies reflect the new ICD-10 codes?
A2. Our medical policies do not contain ICD codes. This will not change due to the introduction of ICD-10. Our internal systems have already been updated to account for the necessary ICD-10 codes to meet the intent of each medical policy.
Q3. Is Wellmark employing any crosswalks for the 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. There will be a period where Wellmark will be simultaneously processing ICD-9 and ICD-10 claims. What are your plans to manage potential problems related to network connectivity, processing time and overall integration during this time?
A4. The Wellmark systems and processes will be updated to handle the ICD-9 claims run-out and the newly submitted ICD-10 claims. Significant volume testing is planned to ensure no interruption to our processing capacity.
Q5. Does Wellmark anticipate any delays in payments due to the switch to ICD-10?
A5. No. We do not anticipate any delays in payments for claims that are submitted correctly.
Q6. Are CPT® and HCPCS codes affected?
A6. No. Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes are not a part of this transition.
Q7. Will Wellmark use ICD-10 PCS coding for outpatient services?
A7. No. We will use 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 outpatient services.
Q8. Does Wellmark require ICD-9 or ICD-10 coding on pre-service review requests?
A8. 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.
Q9. Because 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?
A9. Wellmark will match the claim to the pre-service review request and process the claim accordingly.
Q10. Will Wellmark reject unspecified codes?
A.10 No. However, unspecified codes may have a negative impact on inpatient reimbursement. The lack of specificity may impact the DRG or severity of illness.
Q11. Will Wellmark require additional administrative processes for providers (e.g., more requests for medical records) due to the ICD-10 change?
A11. No. Wellmark has not made any changes to administrative processes in anticipation of ICD-10. However, we have a monitoring program that will evaluate claim receipt, claim adjustment, claim payment, etc.
Q12. The Centers for Medicare and Medicaid Services has 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?
A12. Wellmark will not deny provider 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 will be required on all claims starting on Oct. 1, 2015. It is possible a claim could be chosen for review for reasons other than the specificity of the ICD-10 code.
Q13. What is advanced payment and how can I access this if needed?
A13. Wellmark is ready for the change to ICD-10. However, 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 will not make advance payments in the case where a provider is unable to submit a valid ICD-10 claim.