These FAQs regarding ICD-10 were compiled based on questions received by OHCA and other state Medicaid agencies. If additional questions arise that would benefit the provider community as a whole, they will likewise be posted with the appropriate response.
What is OHCA’s position?
- On April 1, 2014, President Obama signed Congressional Bill HR 4302 into law which delays the implementation of ICD-10 by at least one year from October 1, 2014, to at least October 1, 2015.
- On July 31, 2014, the Department of Health and Human Services (HHS) posted the final rule that formally set the compliance date for ICD-10 to October 1, 2015.
- As a result of the delay, OHCA will continue to accept only ICD-9 codes and deny any ICD-10 codes submitted on a claim until the compliance date now set for October 1, 2015.
What are some of the benefits?
- Updated medical terminology and classification of diseases to be consistent with current clinical practice.
- Improved efficiencies and lowered administrative costs.
- Possible reduction in requests for additional documentation to support claims.
- Better support of medical necessity of services provided.
Who is affected by the transition to ICD-10?
Everyone in health care from patient to payer will be affected by the transition to ICD-10, either directly or indirectly.
What is the difference between ICD-9 and ICD-10?
- There are approximately 69,000 ICD-10 diagnosis codes versus approximately 14,000 ICD-9 diagnosis codes.
- There are approximately 72,000 ICD-10 procedure codes versus approximately 4,000 ICD-9 procedure codes.
- Due to the added complexity and specificity on the ICD-10 codes, some ICD-9 codes do not map to any ICD-10 codes and some ICD-10 codes do not map to any ICD-9 codes.
What happens if I submit ICD-10 codes on a claim prior to the federally mandated implementation date?
- Any ICD-10 codes submitted on a claim prior to the federally mandated implementation date will be denied as an invalid code. Only ICD-9 codes will be accepted until the federally mandated implementation date.
What happens if I don’t migrate to ICD-10 by the compliance date?
- OHCA will not accept ICD-9 codes with dates of service on or after the federally mandated compliance date, currently set for 10/01/2015. Claims submitted after that date, but with dates of service prior to that date, must contain the applicable ICD-9 codes.
- The processing of claims with dates of service that span the mandated implementation date for ICD-10 codes, will be as follows:
Claim type: Institutional (e.g., UB04) Processing: Based on Date of Discharge
·Discharge date before 10/01/2015 submit ICD-9 codes only
·Discharge date on or after 10/01/2015 submit with ICD-10 codes only, regardless of the first date of service (FDOS).
·DO NOT split claims into multiple based on dates of service.
Claim type: Non–Institutional (e.g. 1500) Processing: Based on FDOS of the Claim
·FDOS before 10/01/2015 use ICD-9 codes only
·FDOS on or after 10/01/2015 use ICD-10 codes only
·Pharmacy claims will use dispense date as the FDOS
·MUST split claims that span ICD Code set dates into multiple claims as defined below.
Split Claims Submission and Processing:
For non-institutional claims only, if service dates on a submitted claim are within both the ICD-9 and ICD-10 effective date ranges, the claim will be denied with a new system edit.
In these cases, the claim should be split: one submitted with services within the ICD-9 date span containing ICD-9 codes only, and the other with services within the ICD-10 date span containing ICD-10 codes only.
How will OHCA communicate to affected parties?
- OHCA plans to communicate with affected parties primarily via the provider home page at www.okhca.org , the SoonerCare Provider Portal (secure site), banner messages, EDI emails and remittance advice (RA) messages. In some instances, OHCA may contact providers directly.
- Additional training for ICD-10 in the form of workshops and webinars have been and will continue to be provided prior to the implementation date. See the Training section on the Provider home page at www.okhca.org for more details.
What is OHCA’s status with preparing for the transitions?
- OHCA engaged each of its business areas and conducted an agencywide ICD-10 impact analysis of business processes, policies and systems.
- Results of that impact assessment were used to develop a long-term roadmap identifying what, how and when the required changes will be completed.
- All documents located on the Provide Portal impacted by ICD-10 have been identified and are in the process of being updated accordingly.
- OHCA has completed making necessary system changes and has conducted thorough internal testing of those changes to validate claims are processed appropriately.
What is OHCA’s approach for transitioning between the ICD-9 and ICD-10 code sets?
- OHCA has purchased the 3M™ Code Translation Tool (CTT) to assist with the translation between ICD-9 and ICD-10. The tool is based on the General Equivalency Mappings (GEMS) which were developed by 3M™ under contract for CMS, and they are fully integrated into the tool. It will automate many of the translations between ICD-9 and ICD-10 and identify the translations that require manual intervention and decision making from subject matter experts.
Will there be testing between OHCA and providers?
- OHCA recently completed an initial beta round of external provider testing on August 29, 2014. Currently, three additional rounds of testing are tentatively scheduled as follows:
- Round 1: November 3, 2014 - December 26, 2014
- Round 2: February 2, 2015 – April 30, 2015
- Round 3: June 1, 2015 – August 28, 2015
- OHCA is currently reaching out to specific billing agents and clearinghouses to define which providers will be selected to participate in the next rounds of testing. Each billing agent or clearinghouse will be allowed to select no more than two of the providers for which they submit claims for in production today.
- It’s recommended that providers contact their billing agent or clearinghouse ASAP to let them know whether you’re interested in participating in testing and to see if they’re capable and willing to submit your test claims, if they’re contacted by HP to participate in the testing. You will only be selected for testing if OHCA selects your billing agent or clearinghouse and they, in turn, select you as one of the two providers they’re allotted (as noted in the second bullet above).
- For providers who would like to be considered for testing but do not use a billing agent or clearinghouse - If you are ready to submit test claims and submit your own EDI 837 files, or enter claims directly via the secure Provider Portal, please send an email to the ICD-10 email account at: ICD10project@okhca.org indicating your interest in testing. From the emails received, OHCA will select a defined set of providers to participate in testing depending upon the number of requests. In your email request to test with OHCA, please include all pertinent contact information and which round of testing in which you would like to participate. Such contact information would include:
- SoonerCare provider number and location (e.g. 123456789A)
- Name of organization
- Name, email and phone number of the person responsible for ICD-10 testing
Will the migration to ICD-10 effect reimbursements?
- The impacts on reimbursement are being evaluated for moving from 17,000 to 168,000 codes. It’s possible that with the specificity inherent in the ICD-10 code set, reimbursements may be more directly related to the complexity of treating a member’s condition. However, overall reimbursements must remain budget neutral as required by state law.
What can I do to get prepared regarding education and training?
- Get everyone in the practice involved in the implementation project early.
- Assess educational needs.
- Identify those who will need education and training.
- Identify the type and level of education and training needed.
- Have physician practice coders learn ICD-10-CM, not ICD-10-PCS (which is all they will need).
- Focus on subset of codes used by practice in training physician practice coders who work in a medical specialty area .
- Determine how education will be delivered.
- Inform all staff as to the reasons for moving to ICD-10-CM, the time frame necessary for implementation and how ICD-10-CM impacts the practice.
- Develop materials to disseminate to managers and staff regarding the timeline and status of implementation. Communication might include staff meetings, newsletters, emails or other methods of communication.
- Develop a schedule for when the information will be communicated. Staff members need to understand not just what is happening but what they need to do and how it will impact their work. By communicating this information during the early phase of implementation, managers can make staff members aware of their responsibilities and roles in the implementation process.
- Training schedules and training plans should be communicated to staff early to avoid causing them anxiety about learning ICD-10-CM.
- Conduct periodic briefings for staff to keep the entire practice updated on the progress of the project.
What considerations are there for system changes?
- Planning and preparation should already be underway or started very soon.
- Providers should contact their billing or software vendor to understand their plans for conversion and testing.
- Testing is going to be significant, so identify functionality that needs to be tested and verified; assign specific people to test various elements; and know where your software vendors, clearinghouse or billing agent stand in their own testing readiness.
ICD-10 Resources and Information
- Centers for Medicare & Medicaid Services (CMS):
- Workgroup for Electronic Data Interchange (WEDI):
- World Health Organization (WHO):
- Health Information and Management Systems Society (HIMSS)
For additional questions and direct inquiries regarding ICD-10, please email them to the ICD-10 team at ICD10Project@okhca.org.