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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).
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 should we file a claim that includes services before and after Oct. 1, 2015?
A2. 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 .
Q3. What if a patient is admitted as an inpatient prior to Oct. 1, 2015 and is discharged on Oct. 1, 2015?
A3. ICD-10 diagnoses procedures are required for discharge dates on Oct. 1 2015, and after.
Q4. What is the last date Wellmark will accept ICD-9 codes?
A4. 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.
Q5. Do both electronic and paper claims require ICD-10 coding?
A5. All claims must use ICD-10 coding.
Q6. Which CMS-1500 claim form do I use for dates of service after Oct. 1?
A6. 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.
Q7. On my electronic claim submission (837), which ICD identifier do I use?
A7. With dates of service Oct. 1, 2015, and after, the new ICD-10-CM (diagnosis codes) identifiers must be used. Identifiers are used to indicate the type of ICD-9-CM or ICD-10-CM code that will follow. All ICD-10-CM identifiers are 3-characters in length.
Q8. Which ICD indicator do I use on the claim?
A8. Use ICD-9 indicators for dates of service prior to Oct. 1, 2015 and ICD-10 indicator for dates of service Oct. 1, 2015 and after.
Q9. If we transmit electronic claims, do we need to make any interface or other technical adjustments to ensure complete and accurate transmissions?
A9. 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.
Q10. What do I do if I’m having issues submitting my claim electronically?
A10. 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.
Q11. Do rebills have to be recoded with ICD-10 codes?
A11. 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.
A12. Does Wellmark reject or deny claims for unspecified diagnoses codes?
Q12. 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. 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.
Medical Policies and Pre-service Review
Q1. Has Wellmark changed medical necessity requirements because of the more specific codes?
A1. No. Wellmark has not changed the intent of any of our medical policies due to ICD-10.
Q2. Do Wellmark's medical policies reflect the new ICD-10 codes?
A2. Our medical policies do not contain ICD codes. This has not changed due to the introduction of ICD-10.
Q3. Has Wellmark employed 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. Does Wellmark require ICD-9 or ICD-10 coding on pre-service review requests?
A4. 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.
Q5. 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?
A5. Wellmark will match the claim to the pre-service review request and process the claim accordingly.