ICD-10 is the implementation of International Classification of Diseases, 10th Edition (ICD-10), which represents a significant code set change that impacts the entire health care community. CMS has designated an ICD-10 implementation date of October 1, 2016. ICD-10 consists of two parts:
ICD-10-CM is a Diagnostics Classification System that was Developed to Replace ICD-9-CM (Volumes 1 and 2).
It provides code titles and language that complement accepted clinical practice in the U.S.
Structural differences between ICD-9-CM and ICD-10-CM
|ICD-9-CM Diagnosis||ICD-10-CM Diagnosis|
|3 to 5 characters||7 characters|
|First character is numeric, but can be alpha (E or V)||All letters used except U|
|Positions 2 – 5 are numeric||First character is always alpha; character 2 is always numeric|
|Approximately 14,000 codes||Approximately 69,000 codes|
ICD-9-CM diagnosis code example
- 511.9 unspecified pleural effusion
- V02.61 Hepatitis B carrier
ICD-10-CM diagnosis code example
- A69.21 Meningitis due to Lyme disease
- 52.131a Displaced fracture of neck of right radius, initial encounter for closed fracture
ICD-10-PCS (Procedure Coding System) was Developed as a Replacement for ICD-9-CM, Volume 3.
ICD-10-PCS procedure is much more detailed and specific than ICD-9 and applies to inpatient procedures.
|ICD-9-CM Procedure Codes
|3 to 5 characters||7 characters|
|All digits are numeric||Each digit is alphanumeric|
|Decimal after 2nd digit||No decimal|
|Lacks laterality||Has laterality|
|Uses some outdated and obsolete terminology||Updated medical terminology|
|Generic terms for body parts||Detailed descriptions for body parts|
|Approximately 3,000 codes||Approximately 72,000 codes|
Example: Laparoscopic Appendectomy
- Under ICD-9, would be coded as 47.01
- Under ICD-10, would be coded as 0DTJ4ZZ
What information does an ICD-10 code represent?
In the above example (Laparoscopic Appendectomy), the code designates the following:
|Section||Body system||Root operation||Body part||Approach||Device||Qualifier|
For more information, please contact:
All physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs (HH&H MACs) and Durable Medical Equipment MACs (DME MACs), for services provided to Medicare beneficiaries.
ICD-10-CM will be used by all health care providers in all settings to assign and/or interpret diagnoses.
ICD-10-PCS will capture inpatient procedures for acute care hospital claims.
CPT-Codes: When ICD-10-CM/PCS is implemented on October 1, 2016, it will not affect use of CPT codes by physicians, outpatient facilities, and hospital outpatient departments on Medicare Fee-For-Service claims.
Beyond the surface of having to learn a new code set, the transition from ICD-9 to ICD-10 will affect many areas of provider organizations. Areas of impact often include:
- Physicians: documentation and code training
- Nurses: forms, documentation, prior authorizations
- Lab: documentation and reporting
- Billing: policy and procedures, reporting
- Coding: code set training, clinical knowledge, and concurrent use (with ICD-9)
- Clinical Areas: patient coverage
- Operations: policies and procedures, vendor/payer contracts, budgets, training
- Administration: HIPAA, system upgrades, testing/validation and readiness
More information around transition planning for provider organizations may be found at
The CMS 1500 claim form is the required format for submitting claims to Medicare and/or Elderplan on paper. The National Uniform Claim Committee (NUCC) recently revised this form issuing a new version (02/12), which is required when submitting claims containing ICD-10 codes.
The CMS 1500 claim form is the required format for submitting paper claims for Medicare. The form was recently changed to accommodate the use of ICD-10 codes, which is reflected in Version 02/12. This change does not affect claims submitted electronically.
If you use the CMS 1500 form – What you need to do
- Make sure your billing staff understands instructions for filling out the new form (there have been over a dozen changes). The instruction manual may be found at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2842CP.pdf.
- Talk to your practice management system vendor about upgrades needed for the form.
- Use up your stock of 08/05 forms and order 02/12 forms (talk to your forms vendor).
- You may begin using this newly revised form immediately. Elderplan will accept either version (08/05 or 02/12) of the CMS 1500 form; however, claims submitted with ICD-10 information must be submitted on the 02/12 version only.
- Box 17: the addition of identifiers in the left hand side to designate provider roles (valid qualifiers are provided in the 02/12 instruction manual).
Box 21 of the form provides for:
- Added 8 additional lines for diagnosis codes (12).
- Adds an ICD indicator to designate whether the codes are ICD-9 (enter “9”) or ICD-10 (enter “0”).
Common mistakes that may slow processing of paper claims:
|MISTAKE||CMS 1500 (aka HCFA) Box #||UB form box #|
|Missing Rendering NPI||24J||–|
|Missing servicing facility (when applicable) or billing provider info||32, 33||–|
|Incorrect EP member ID (Common mistakes, providers submit SS #, Medicare # or Medicaid #)||1a||8a, 60 a-c|
|Incorrect member DOB||3, 11a||10|
|Invalid diagnosis codes (insufficient specificity) or mixed (ICD-9 and ICD-10) codes on same claim||21||–|
|Invalid Type of Bill||na|
Additional questions should be addressed to Elderplan Provider Services at 718-921-7979 or via email to EPProviderServices@mjhs.org.
For a complete list of the changes from the current (08/05) version to the revised (02/12) version, view the Change Log Document (PDF) at the following link: http://www.nucc.org/images/stories/PDF/version_0212_1500_change_log.pdf.
While the needs of each organization vary with respect to ICD-10, some basic knowledge and milestones are common to most. CMS has recommended the following medical codes training timelines:
- Provide intensive training no sooner than six to nine months prior to implementation for coders who will not assign ICD-10-CM/PCS codes until compliance date.
- Provide 50 hours training to hospital inpatient coders (ICD-10-CM and ICD-10-PCS).
- Provide 16 hours training to other coders (ICD-10-CM only).
ICD-10 coding training will be integrated into the continuing education units (CEUs) that certified coders must take to maintain their credentials.
Specialists will want to look for specialty-specific ICD-10 training offered by societies and professional organizations.
ICD-10 resources and training materials will be available through CMS, professional associations and societies, and software and system vendors.
Look for additional training guidance to be added to the Elderplan provider portal over the coming weeks.
Other ICD-10 training resources:
- Basic (self-directed) Training (internal and external): http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050367.hcsp?dDocName=bok1_050367
- GEMS Crosswalk documents: http://cms.hhs.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMS.html
- Advanced Provider Training (e.g., HIMSS ICD-10 podcasts for providers by provider type): http://www.himss.org/library/podcasts/icd-10-provider?navItemNumber=17054
There are numerous industry resources that address requirements, planning, training and more to help providers make a smooth transition to ICD-10.
We encourage providers to obtain updates from CMS as well as any professional, clinical and trade associations with which you may be affiliated for a wide variety of ICD-10 information, educational resources, checklists and updates to assist you with this transition. Some select sources follow:
- Elderplan Provider Service: Phone 718-921-7979 or via email to EPProviderServices@mjhs.org
- Elderplan Website Portal: http://elderplan.org/for-providers/
- CMS: http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10/
- Workgroup for Electronic Data Interchange (WEDI): http://www.wedi.org/topics/icd-10
- ICD-10-CM (diagnosis) code sets: http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10/12_2010_ICD_10_CM.asp
- ICD-10-PCS (hospital inpatient procedure) code sets: http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10/13_2010_ICD10PCS.asp
- American Health Information Management Association (AHIMA): http://www.ahima.org/
What is ICD-10?
ICD-10 is the International Classification of Diseases, version 10. ICD is the international standard for diagnostic classifications. The current version, ICD-9, was adopted in 1979.
What does ICD-10 compliance mean?
All HIPAA-covered entities must be able to successfully conduct health care transactions, using the ICD-10 diagnosis and procedure codes.
What changes are occurring in the ICD-10 version?
The changes will impact ICD-9-CM diagnosis codes and ICD-9-CM procedure codes. The diagnosis codes for ICD-9 are currently three to five digits that are alphanumeric in nature and combine to make approximately 13,000 unique diagnosis codes being used today. For ICD-10, the diagnosis codes will be seven digits that are alphanumeric in nature and combine to make around 68,000 unique diagnosis codes. Currently, ICD-9 procedure codes are three to four digits that are numeric in nature and combine to make about 3,000 unique procedure codes. For ICD-10-PCS (inpatient), the procedure codes will be seven digits that are alphanumeric in nature and combine to make around 72,000 unique procedure codes.
Who is affected by the transition to ICD-10?
All entities covered by HIPAA have been designated for transition to ICD-10 by CMS. This includes both Medicare and commercial lines of business. For clarification on claims whose date of service spans the 10/1/15 implementation date, see CMS MLN: SE1408 (revised 2/20/15).
What happens if I don’t switch to ICD-10?
Claims that do not contain ICD-10 diagnosis and inpatient procedure codes after the implementation date will not be considered HIPAA compliant as defined by regulations enforced by CMS. Claims for all services and hospital inpatient procedures performed on or after the compliance deadline must use ICD-10 diagnosis and procedure codes (This does not apply to CPT coding for outpatient procedures). Claims that do not use ICD-10 diagnosis and inpatient procedure codes, cannot be processed for dates of service > 10/1/16.
Will there be a period of time when both codes will be required on the same claim?
No. Per CMS guidance, ICD-9 codes will no longer be utilized on institutional, professional or supplier claims (including electronic and paper) with FROM dates of service or dates of discharge THROUGH dates on or after October 1, 2016. A claim submission, either in EDI or paper formats, cannot contain both ICD-9 codes and ICD-10 codes.
Will Elderplan support dual processing of ICD-9 and ICD-10 codes?
Elderplan will support dual processing in compliance with CMS. Only ICD-10 codes will be accepted for dates of service beginning 10/1/16. Claims with dates of service prior to 10/1/15 shall use ICD-9 codes. Certain inpatient claims with dates of service spanning the 10/1/16 implementation may be submitted using ICD-9 (see CMS Transmittal 950 for details). All other ICD-9 claims with dates of service > 10/1/16 will be rejected.
Will Elderplan accept ICD-10 codes before the implementation date?
If my practice is not ready for ICD-10 by October 1, 2016, can I drop my claims to paper and continue using ICD-9?
No. Form CMS-1500 version 12/02 provides for submission of ICD-10 based paper claims. Elderplan will assist providers with timely requests for training and testing to help improve readiness to submit ICD-10 claims effective 10/1/16.
Can I submit both ICD-9 and ICD-10 codes on the same claim?
No. Only one version of ICD codes can be submitted on a claim. If both ICD-9 and ICD-10 codes are submitted on a claim, the claim is rejected as a claims submission error. If ICD-9, the “indicator” in field 21 of CMS 1500 form, should be “9.” If ICD-10, the indicator in field 21 of CMS 1500 form should be “0.”
How do I handle split billing of claims that span the ICD-10 compliance date? For example, a patient was seen from September 30, 2016, through October 2, 2016. Can I submit one claim for all the services covered through these dates?
a. Only one version of ICD codes can be submitted on a claim. In the example above, if the claim was for an outpatient visit, the claim would be split into two claims with the services performed on September 30, 2016, on one claim using ICD-9 diagnosis codes and services performed on October 1 and October 2, 2016, on another claim using ICD-10 diagnosis codes. For an inpatient claim, the general rule of thumb is to use the date of discharge (DOD); if the DOD is September 30, 2016, or before, submit the claim using ICD-9 codes, and if the DOD is October 1, 2016, or after, code the claim using ICD-10 codes. There are specific directions by bill type for facility claims and for some professional claims scenarios such as anesthesia.
b. Please refer to CMS Transmittal 950 for specific direction on handling claims that span the ICD-10 compliance date.
What will the appeal process be for resubmission of ICD-9-based claims with ICD-10 codes during transition period?
The appeal and resubmission process will follow the current process. The level of clinical documentation must support the diagnosis information as submitted on the claim submission.
What changes in payment will there be with the change to ICD-10?
For inpatient procedures, Elderplan provides reimbursement according to the contract terms utilizing current diagnosis related group (DRG). We anticipate utilization of DRG version 33 to support ICD-10 reimbursement. All other rates are based on CPT code. Actual reimbursement will be dependent on the claim type and product against which it is submitted.
Should providers expect delays in payment during the transition from ICD-9 to ICD-10? Will Elderplan provide interim payments to offset potential delays in payment?
There is no Elderplan planned delay or modification of the current reimbursement process as a result of ICD-10 implementation. Accordingly, interim payments are not applicable.
Does Elderplan have a goal for medical loss ratio neutrality included in its ICD-10 transition?
There is no plan to modify existing reimbursement terms or policies specific to ICD-10.
Will Elderplan revise medical review policies, coverage determinations and payment determinations due to ICD-10?
Elderplan has no plan to modify existing policies and procedures. If changes are anticipated, providers will be proactively informed as part of our provider outreach.
Will you renegotiate provider contracts to replace ICD-9 codes with ICD-10 codes?
We anticipate minimal contracts have sensitivity to ICD-10 transition. If your contract has specific ICD or DRG language, please contact your Elderplan provider representative to facilitate a contract revision. Any contract changes will follow the normal process.
Why is the transition to ICD-10 any different from the annual ICD-9 code change?
ICD-10 is more robust and descriptive. ICD-9 codes are numeric and have three to five digits, whereas ICD-10 codes will be alphanumeric and contain three to seven characters.
What claim-processing issues does Elderplan anticipate with the preparation for ICD-10?
Elderplan is investing in remediation of systems and processes to support the ICD-10 requirements. Elderplan does not foresee any issues with claims processing with the change to ICD-10, although claim rejection due to misuse of new ICD-10 codes is possible. Testing is underway to mitigate any such issues.
Will there be special handling for patients who are in-house over the transition?
Yes. Claims for inpatients over the transition date should be submitted based on the “through” date using published CMS recommendations.
For non-DRG based payment models, how does your organization think the methods of payment will be impacted by ICD-10?
Elderplan has no modification to the existing reimbursement terms or policies specific to ICD-10.
When will your organization be ready to accept/receive ICD-10 test transactions?
Elderplan is currently testing ICD-10 claims with providers. If your organization would like to register to test ICD-10 claims with Elderplan, please log in to the Provider Portal HomePage. Under the “What’s New” tab, select “ICD-10 Testing with Providers” and register to participate.
Do you intend to change medical necessity requirements because of the more specific codes that will be available?
Elderplan will continue to utilize the medical necessity polices from CMS and NYS for our various plans. These standards have been revised for ICD-10, and Elderplan will be using the current standards.
What is the plan to manage the potential increase in denials/appeals?
The most effective method to reduce denials and appeals is for all parties to be ready to submit valid ICD-10 claims. Providers are highly encouraged to take reasonable steps to prepare for ICD-10 well in advance of their planned use (e.g., we are anticipating some providers will be requesting pre-authorization for ICD-10 procedures 60 – 90 days earlier). Elderplan’s provider portal describes and references how providers can become ready so as to minimize denials and appeals.
What is the plan for denial remediation/communication/feedback to providers?
EDI Claims with syntactical errors will be “rejected” via a 277CA. Non-rejected claims would be “denied” based on appropriateness criteria (e.g., lack of benefit, inappropriate service for gender or age, etc.).
If an electronic claim is rejected, what are the options for getting it processed?
If an electronic claim is rejected, the submitting provider will receive a “reject” notification in the same form as submitted. The claim can either be changed and resubmitted or submitted as a paper claim using a standard CMS 1500 form.
What key information should health care providers keep in mind as they develop their own ICD-10 implementation plans?
Elderplan suggests that health care providers stay up-to-date on any changes by CMS regarding ICD-10 implementation by monitoring the CMS website as well as other resources listed below. If health care providers have questions or concerns, they may submit an email to EPProviderServices@mjhs.org.
Where can I find the ICD-10 code sets?
The ICD-10-CM, ICD-10-PCS code sets and the ICD-10-CM official guidelines are available free of charge at http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html.
CMS has delayed implementation of ICD-10 until 2016. How will this affect the work Elderplan already has underway?
Elderplan will continue appropriate work toward ICD-10 implementation with minimal interruption.
Part of Elderplan’s ICD-10 implementation includes working with providers to conduct testing of claims from submission through validation of payment information. We encourage all providers to actively take advantage of this bigger window for ICD-10 remediation including testing with Elderplan, regardless if you are ready to test today or won’t be ready for months.
Will Elderplan be compliant by the October 1, 2016, deadline?
Yes. We are working to help ensure our systems, supporting business processes, policies and procedures successfully meet the implementation standards and deadlines without interruption to day-to-day business practices. We plan to work closely with providers, clearinghouses, vendors and state partners as they also work towards meeting this compliance date.