ICD-10 General Questions
Q1. What are the ICD-10 final rule compliance requirement?
A1. The ICD-10 Final Rule mandates the use of two code sets by October 1, 2015: ICD-10-CM for diagnostic conditions and ICD-10-PCS for in-patient 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. Everyone covered by HIPAA must transition to ICD-10. This includes providers and payers who do not deal with Medicare claims.
Q3. Codes change every year, so why is the transition to ICD-10 any different from the annual code changes?
A3. 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.
Q4. Will there be a crosswalk document available?
A4. 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.
Q5. Are you prepared to meet the ICD-10 deadline of October 1, 2015?
A5. Yes. We are ready to meet the nationally set guidelines and timelines. We have implemented our ICD-10 changes into production for our claims receipt, processing and payment systems. We continue to complete final changes to our downstream systems (data warehouse, web based applications, etc.).
Q6. Will you be required to fully upgrade your system(s) or will you only be installing a fix or patch?
A6. Wellmark is fully upgrading its systems for ICD-10.
Q1. When will Wellmark begin accepting ICD-10 codes on our 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 before that date.
Q2. 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?
A2. Per the mandate, claims with service dates on or after October 1, 2015, must process using ICD-10 codes, while 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, refer to the tables in CMS ruling (CR #7492). Wellmark will communicate any deviations from the CMS guidance in future issues of BlueInk on our ICD-10 website page.
Q4. When is the last date Wellmark will accept ICD-9 codes?
A4. For most Wellmark members, you currently have 365 days from the date of service to file a claim for the first time. This means that services provided, for example, on September 30, 2015, must be filed by September 30, 2016, 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. Note: Effective January 1, 2015 the timely filing guidelines will be changing from 365 days to 180 days; refer to your contract for additional details.
Q5. Will both electronic and paper claims require ICD-10 coding?
A5. All claims need to be compliant.
Q6. If we transmit electronic claims, do we need to make any interface or other technical adjustments to assure 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 there be a crosswalk document available?
A7. 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.
Q8. Will rebills have to be recoded with ICD-10 codes?
A8. 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.
Q9. Are there any changes planned on how to submit claims containing ICD-9 and/or ICD-10 codes?
A9. 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.
A10. Will you be rejecting or denying claims for unspecified diagnoses codes?
Q10. No, we did not add 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. 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, 2015, will be based on ICD-9 diagnosis and procedure codes. Reimbursement for dates of service on and after October 1, 2015, 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.
Q1. Do you intend to change medical-necessity requirements because of the more specific codes that will be available?
A1. No, Wellmark is not changing the intent of any of our medical policies due to ICD-10.
Q2. When are you going to communicate/publish the ICD 10 medical Policies and Edits?
A2. Our Medical Policies do not contain ICD-9 codes and will not change based on 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. 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. How will your organization communicate about the ICD-10 transition?
A5. Email, Frequently Asked Questions will be posted on www.wellmark.com, ICD-10 articles will be published within our Blue Ink
Q6. Do you anticipate any delays in payments to result from the switch to ICD-10?
A6. We do not anticipate any delays in payments for claims that are submitted correctly.
Q7. 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?
A7. 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.
Q8. How are CPT® and HCPCS codes affected?
A8. No, current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes are not a part of this transition.
Q9. Will Wellmark use ICD-10 PCS coding for outpatient services?
A9. 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.
Q10. What is Wellmark's contingency plan for ICD-10?
A10. We will follow any updates by CMS by adjusting our guidelines appropriately.
Q11. How would Wellmark recommend home care claims be billed where the 60 day certification period spans Oct. 1, 2015?
A11. 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, 2015) 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.
Q12. Will Wellmark require any certification process for ICD-10?
A12. No, we will not require you to pre-certify to send claims containing ICD-10 codes.