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The Health Insurance Portability and Accountability Act (HIPAA) requires all affected entities (e.g., health plans, hospitals, clearinghouses) to follow specific standards when transmitting electronic data for health care administrative transactions. ConnectiCare has been working to take the necessary steps to be compliant with these ICD-10 standards.
Getting Ready for the ICD-10 Conversion
Q: What is ConnectiCare doing to get ready for the ICD-10 conversion?
A: ConnectiCare has completed business assessments for all affected areas. ConnectiCare has been working to execute a multi-year plan incorporating system design and development, development of business processes and policies, and communication and training.
Q: Will ConnectiCare be ready to accept ICD-10 codes on Oct. 1, 2015?
A: Yes, ConnectiCare will be ready to accept and process ICD-10 codes on Oct. 1, 2015.
Q: What is ConnectiCare’s position on submission of ICD-10 codes?
A: ConnectiCare will require that only ICD-10 codes be submitted on claims for dates of service on or after Oct. 1, 2015, and on claims involving inpatient discharges on or after Oct. 1, 2015.
Transitioning from ICD-9 to ICD-10
Q: What is ConnectiCare’s approach to mapping ICD-9 codes to ICD-10 codes?
A: The Centers for Medicare & Medicaid Services has provided General Equivalency Mappings (GEMs) as guidance for reasonable alternatives for mappings between ICD-9 and ICD-10 codes. While the GEMs provide guidance and a starting point for crosswalk development, there is currently no industry standard for mapping. ConnectiCare is using the CMS GEMs as a clinical reference tool to remediate business rules with ICD-9 codes.
Q: Will ConnectiCare use a crosswalk for claims processing?
A: No. Starting on Oct. 1, 2015, standard transactions must be submitted with ICD-10 codes. After Oct. 1, 2015, ConnectiCare will process claims submitted with ICD-9 codes only for dates of service (outpatient) or dates of discharge (inpatient) prior to Oct. 1, 2015.
Q: Will ConnectiCare support dual intake of codes?
A: ConnectiCare is prepared to accept both ICD-9 and ICD-10 codes for a period of time after Oct. 1, 2015. ConnectiCare will process claims submitted with ICD-9 codes only for dates of service (outpatient) or dates of discharge (inpatient) prior to Oct. 1, 2015. Claims with dates of service (outpatient) or dates of discharge (inpatient) after Oct. 1, 2015, must be submitted with ICD-10 codes in order to be accepted for processing. ConnectiCare will continue to closely follow the communications from CMS, and will adapt our approach as necessary.
Q: What will happen to the claims if ICD-9 codes are submitted for dates of service (outpatient) and dates of discharge (inpatient) after Oct. 1, 2015?
A: Those claims will not comply with the ICD-10 standards so they will not be paid. Providers will have to resubmit the claims with the correct ICD-10 codes.
Q: What will happen to the claims if ICD-10 codes are submitted for dates of service (outpatient) and dates of discharge (inpatient) before Oct. 1, 2015?
A: Those claims will not be paid and providers will have to resubmit the claims with the correct ICD-9 codes.
Q: What should providers do for outpatient claims that have service dates close to Oct. 1, 2015?
A: In those instances, providers must split the outpatient claims into separate claims and use:
Q: Will ConnectiCare accept ICD-10 codes prior to Oct. 1, 2015?
A: No. ConnectiCare will accept ICD-9 diagnosis codes for all claims with dates of service prior to Oct. 1, 2015. ConnectiCare will accept ICD-10 codes for claims with dates of service (outpatient) or dates of discharge (inpatient) after Oct. 1, 2015.
What You Need To Do To Be Ready
Q: What should physician practices and facilities do to prepare for the switch to ICD-10?
A: ConnectiCare recommends that physician practices and health care facilities plan and prepare for the ICD-10 conversion well in advance of Oct. 1, 2015. The conversion affects nearly all provider systems. The largest impacts will likely be on clinical and financial documentation, billing and coding.
Your office should contact your practice management software vendor to ask about its ICD-10 conversion plan and testing strategy. You should also contact the claims clearinghouse where you submit claims electronically to ask what you need to do before Oct. 1, 2015.
Q: Will providers be required to purchase any additional equipment, software licenses or subscription fees to support ConnectiCare’s ICD-10 changes or enhancements?
A: Possibly. Providers will be expected to submit ICD-10 compliant claims after Oct. 1, 2015. Each provider will need to determine what is needed to operate in an ICD-10 environment.
ICD-10 Impact on Reimbursement and Contracting
Q: Will the ICD-10 conversion have an effect on provider reimbursement and contracting?
A: CMS intended the ICD-10 conversion to be financially neutral. But CMS acknowledges the use of the more detailed codes of ICD-10 could affect reimbursements. The financial impact of ICD-10 may vary based on your contract(s) with ConnectiCare, but we are committed to minimizing this impact. We plan to maintain consistency in how claims are paid and benefits applied and to ensure that neither party is unduly harmed or benefited by the ICD-10 conversion.
Q: What is ConnectiCare’s approach towards contract review and revision in the ICD-10-CM/PCS environment (e.g., addendum to existing agreement or renegotiation of contract)?
A: ConnectiCare will work to ensure a seamless conversion to ICD-10 coding to be implemented within the time frames required by law. It is the intent of ConnectiCare to assure budget neutrality regarding any needed rate modifications, as defined below, prior to the mandated implementation date. ConnectiCare will make sure no provider is harmed or benefited from the introduction of and conversion to the new ICD-10 coding system.
ConnectiCare also recognizes that the transition to ICD-10 may affect MS-DRG assignment and therefore modification of negotiated rates may be necessary to hold both parties protected from any material financial impact from the transition.
Both parties agree that if the conversion to the ICD-10 coding system constitutes a material financial impact, they will work cooperatively on an evaluation of the impact and its resolution. Once the impact has been agreed to, rates will be adjusted prospectively as needed, unless it is determined by both parties that a Rate Modification is not required.
ICD-10 and Preauthorization Requests and Medical Policies
Q: Do providers have to do anything different with preauthorization requests on or around Oct. 1, 2015?
A: For ConnectiCare’s Commercial Plans: Preauthorization requests for dates of service on or after Oct. 1, 2015, will require ICD-10 diagnosis codes. For inpatient preauthorization requests, the diagnosis codes should be based on dates of discharge: ICD-9 before Oct. 1, 2015, or ICD-10 after Oct. 1, 2015.
To ensure authorizations have the appropriate diagnosis on record, providers will now be required to provide the actual diagnosis code(s) when requesting preauthorization for services. ConnectiCare case managers will no longer assign a diagnosis code based on a written description of the diagnosis.
For ConnectiCare’s Medicare VIP Plans: The diagnosis codes to be used will be based on when the preauthorization requests are submitted. If the preauthorization request is submitted for your Medicare patient before Oct. 1, 2015, please use ICD-9 codes. If the request is submitted after Oct. 1, 2015, use ICD-10 codes.
Q: How will medical policies be remediated to support ICD-10? When will these changes be communicated to providers?
A: There are only a small number of medical guidelines with implications for ICD-10. These medical guidelines have been remediated and will be updated accordingly. Provider resources containing diagnosis codes will be updated with ICD-10 codes and will be available online closer to the implementation date.
Q: Will reporting formats, e.g., encounter, paid claim or audit reports be changed?
A: There are no proposed changes to our current reporting other than field sizes warranted by the new increased field lengths of the diagnosis codes as applicable.
Q: Will ICD-10 affect CPT or HCPCS codes?
A: No. The transition to ICD-10 does not affect the use of Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes. If you currently bill using CPT/HCPCS codes, continue to do so. However, you will still need to prepare for ICD-10 to provide accurate diagnosis codes on prior approval and referral requests and claims.
For additional information regarding ICD-10, please refer to the following websites:
Centers for Medicare and Medicaid Services (CMS)
CMS’ Road to 10: The Small Physician Practice's Route to ICD-10
National Center for Health Statistics (NCHS)