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Frequently Asked Questions

1. What does ICD-10 compliance mean?

ICD-10 compliance means that everyone covered by HIPAA is able to successfully conduct health care transactions using ICD-10 codes.

2. Will ICD-10 replace Current Procedural Terminology (CPT) procedure coding?

No. The switch to ICD-10 does not affect CPT coding for outpatient procedures. Like ICD-9 procedure codes, ICD-10-PCS codes are for hospital inpatient procedures only.

3. Who is affected by the transition to ICD-10?

Everyone covered by HIPAA must transition to ICD-10. This includes providers and payers who do not deal with Medicare/Medicaid claims.

4. What happens if I don’t switch to ICD-10?

Claims for all services and hospital inpatient procedures performed on or after the compliance deadline must use ICD-10 diagnosis and inpatient 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. It is important to note, however, that claims for services and inpatient procedures provided before the compliance date must use ICD-9 codes.

5. If I transition early to ICD-10, will SCDHHS be able to process my claims?

No. SCDHHS and other payers will not be able to process claims using ICD-10 until the compliance date.  

6. Codes change every year, so why is the transition to ICD-10 any different from the annual code changes?

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. Like ICD-9 codes, ICD-10 codes will be updated every year.

7. 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 www.cms.gov/ICD10.

8. What is your approach to testing? Will you conduct testing with providers?

Large-scale internal testing of ICD-10 will start during the third quarter of 2014.  Targeted Pilot Testing will begin in April 2015 and Open Testing will begin in May 2015.

9. Will SCDHHS support dual intake of codes?

ICD-10 diagnosis and procedure codes are required on claims that contain Dates of Service or Dates of Discharge of 10/1/2015 or after.

ICD-9 diagnosis and procedure codes will be required on claims that contain Dates of Service or Dates of Discharge of 9/30/15 and before.

Claims submitted with both ICD-9 and ICD-10 codes will be rejected. You must submit two different claims based on Dates of Service or Date of Discharge.

10. How should Providers submit claims that span Dates of Service prior to and after the 10/1/2015 compliance date?

Claims submitted with both ICD-9 and ICD-10 codes will be rejected.  You must submit two different claims based on Dates of Service or Date of Discharge.  Only one version of ICD codes can be submitted on a claim.

If the claim was for an outpatient visit, the claim would be split into two claims with the services performed on September 30, 2015 or before, on one claim using ICD-9 diagnosis codes.  Services performed on October 1 or after must be submitted on another 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, 2015, or before, submit the claim using ICD-9 codes, and if the DOD is October 1, 2015, or after, code the claim using ICD-10 codes.

11. SCDHHS requires Prior Authorization (PA) for medically necessary services for Medicaid members as determined by the member's health care provider.  In preparation for the ICD-10 compliance date of Oct. 1, 2015, are there any changes to how providers submit PA requests that span Dates of Service prior to and after the Oct. 1, 2015, compliance date?

No.  Providers will continue to submit PAs based on the instructions in the Provider Manual.

Here is the link to CMS claims submissions related to ICD-10: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1408.pdf

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