Frequently Asked Questions
What is ICD‐10?
ICD‐10 is the International Classification of Diseases, Volume 10. On Jan. 16, 2009, the U.S. Department of Health and Human Services (DHHS) released the final rule mandating that all parties covered by the Health Insurance Portability and Accountability Act (HIPAA) must implement the ICD‐10 diagnosis and ICD‐10 procedure codes for medical coding. This mandate applies to all health plans and all medical transactions that currently use ICD codes. Subsequent changes to the mandate have made ICD-10 diagnosis and ICD-10 procedure codes effective for dates of service or dates of discharge on or after October 1, 2015. ICD‐10 codes are more specific and numerous than ICD‐9 codes. The new codes will have a profound effect on almost every aspect of the health care industry. It is imperative for all providers to submit the correct ICD-10-CM codes on claims for dates of service on or after Oct. 1, 2015! To avoid delays in processing or potential requests for medical records, please be sure to code for all patient conditions and not just the primary condition the patient presents.
What is your ICD‐10 implementation plan?
BlueChoice HealthPlan began accepting ICD-10 codes on Oct. 1, 2015, as mandated by DHHS.
Will all other codes end with the ICD‐10 implementation?
The ICD-10 implementation will not affect the use of other codes (CPT‐4, HCPCS, Revenue Codes, Mental Health DSM-5, etc.). ICD‐9 codes will still apply for dates of service or dates of discharge before October 1, 2015. The mandate requires ICD‐10 diagnosis and procedure codes on all inpatient claims with discharge dates on or after October 1, 2015. The mandate requires ICD‐10 diagnosis codes on all professional and outpatient claims with dates of service on or after Oct. 1, 2015.
Are state and federal health plans (Medicaid, Medicare, FEP, TRICARE) exempt from the ICD‐10 mandate?
No, all health plans must comply with the ICD-10 mandate.
Which electronic transactions will be affected by ICD‐10?
ICD‐10 will affect these electronic transactions: 837 I Institutional Medical Claim; 837 P Professional Medical Claim; 270/271 Eligibility Request/Response; 278 Request for Review and Response.
Will there be changes to the CMS‐1500 (“HCFA”) paper claim form?
The CMS-1500 paper claim form (version 02-12) has been changed to accommodate the use of ICD-10 diagnosis codes. You can find information at www.nucc.org.*
Will there be changes to the UB‐04 paper claim form?
The National Uniform Billing Committee (NUBC) changed the 2012 UB-04 (v.6) paper claim form to accommodate the use of ICD-10 codes. You can find information at www.nubc.org.*
Can I use ICD‐9 and ICD‐10 codes on the same claim? No, you may not file a claim with both ICD-9 and ICD-10-CM codes. You will need to file ICD-9 codes on one claim, and file ICD-10-CM codes on a separate claim.
What should I do if our claims are continually rejected or denied for ICD-10 coding?
You can use My Insurance ManagerSM to submit ICD-10 compliant claims to our plans or resubmit a corrected claim through your clearinghouse.
Please explain the qualifier in block 21. Do we enter that on the hard copy claim?
Our preferred method is to have you submit claims to us electronically. We have a website available for you to key claims if you do not have systems programmed to electronically submit to us. If you are filing your claims hard copy you should indicate ICD-10-CM coding with a “0” in block 21. The ICD Code Qualifier identifies whether the diagnosis code used on a hard copy paper claim is ICD-9 or ICD-10. ICD-9 codes are identified with a “9” and ICD-10 codes are identified with a “0”.
Will BlueChoice® follow Medicare’s one year allowance to accept all claims as long as the code is in the correct “code family”?
CMS is providing a grace period on penalties associated with Medicare Part B claims as long as the codes filed are within the same family. They are still requiring correct coding. BlueChoice expects providers to file claims with the correct ICD-10-CM code as of the mandate date, 10/1/2015.
Will our claims reject if we submit RT/LT modifiers?
We still require modifiers (including RT/LT) on procedure codes even if the diagnosis code specifies laterality. Procedure code requirements have not changed.
Should all claims for dates of service prior to 10/1/2015 use ICD-9-CM codes if we submit the claim as late as October or November?
We determine ICD-10-CM claims filing by the date of service. For services provided prior 10/1/2015, you should continue to file with ICD-9-CM codes regardless of when you file the claims to us.
Are claims processed by date of service or date of claim submission?
We process claims by the date of service. We do, however, track the date of submission for reporting purposes (timeliness).
Will we be able to appeal claims filed with ICD-9-CM codes with DOS after 10/1/2015?
If you receive a denial on a claim because you filed an ICD-9-CM code instead of the ICD-10-CM code, you can file a corrected claim with the ICD-10-CM code to have the claim reconsidered for payment.
Does the ICD-10-CM affect dental codes?
This change impacts all dental claims that are filed through the patient’s medical benefit. An example of a dental/oral surgical procedure that we may cover under medical is the extraction of an impacted tooth.
Will you require external cause of injury codes when we submit ICD-10-CM codes for fractures, sprains or strains on a claim?
Yes, you have to report the appropriate ICD-10-CM code that includes the reference to external cause of injury when you submit the claim. The codes corresponding to ICD-9-CM V codes (Factors influencing Health Status and Contact with Health Services) and E codes (External Causes of Injury and Poisoning) are incorporated into the main classification of ICD-10-CM codes rather than separated into supplementary classifications as they were in ICD-9-CM.
Will diagnosis and procedure codes change or remain the same?
We expect CMS to update ICD-10-CM codes periodically just like the ICD-9 codes have changed in the past. The mandate is specific to ICD-9-CM diagnosis and procedure codes converting to ICD-10-CM. Annual updates are posted in July, effective October 1 of that year through September 30 of the following year. For more information, go to https://www.cms.gov/Medicare/Coding/ICD10/index.html.*
Do you require us to file all ICD-10-CM codes with seven alphanumeric characters?
Certain ICD-10-CM categories have applicable seventh characters. We require the applicable seventh character for all codes within the category, or as the notes in the Tabular List instruct. The seventh character must always be the seventh character in the data field. If a code that requires a seventh character is not six characters, you must use a placeholder X to fill in the empty characters. You can find additional ICD-10-CM coding guidelines at: https://www.cms.gov/Medicare/Coding/ICD10/Downloads/icd10cm-guidelines-2015.pdf.*
In a physical therapy office, do we add A, D or S to the end of the codes?
Most categories have seventh character extensions that are required for each applicable code, and most categories have three extensions (with the exception of fractures): A = Initial encounter (patient receiving active treatment for injury, such as surgical treatment, emergency department encounter and evaluation/treatment by new physician, e.g., S0195XA - Open bite of unspecified part of head, initial encounter). D = Subsequent encounter (patient received active treatment of the injury and receiving routine care for injury during the healing or recovery phase, such as cast change/removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow-up visits following injury treatment, (e.g., S0195XD - Open bite of unspecified part of head, subsequent encounter). S = Sequela (used for complications or conditions that arise as a direct result of an injury, such as, scar formation after a burn, e.g., S0195XS - Open bite of unspecified part of head, sequela).
Do you require the decimal or not when submitting codes?
Yes, we require the decimal only when you submit claims through the Web. We do not require the decimal in the electronic claim and the paper UB-04. It is optional on the CMS-1500 professional claim form and the ADA-JD430 dental claim form.
What does the “F” in front of the ICD-10-CM code signify?
Each alphanumeric digit corresponds to a category (family) of codes in the ICD-10-CM. The ‘F’ is assigned for mental and behavioral health disorders.
I am curious how ICD-10-CM will affect mental health professionals who are not Medicare or Medicaid providers. Will it change our CPT codes or will you use it in place of DSM-5 diagnosis codes?
There is no impact to CPT coding with this mandate. DSM-5® contains both ICD-9-CM and ICD-10-CM codes, therefore for dates of service after 10/1/2015 use the appropriate ICD-10-CM codes. You can find more information about ICD-10 and DSM-5 at http://www.dsm5.org/Pages/Default.aspx.*
Do we need to update diagnosis codes for existing authorizations for ongoing services?
No. If you get an authorization with an ICD-9-CM code for care with a begin date of service (DOS) before October 1, 2015, you will not need an update if the end date of service goes beyond October 1, 2015. The existing authorization will remain valid.
If I have a previous authorization with an ICD-9-CM code for a date of service before 10/1/2015 but then change the patient’s visit to a date after 10/1/2015, do you require me to get a new authorization?
Yes, if you change the date of service to a later date after ICD-10 implementation, you will need to get a new authorization.
If we have a pregnant patient that comes into the office, and we get an authorization for her pregnancy before October 1, 2015, does this mean we have to get a new pregnancy authorization after October 1, 2015?
No, you will not have to obtain a new pregnancy authorization.
For durable medical equipment (DME) rentals, will I need to get a new authorization for service that spans October 1, 2015?
For services starting before October 1, 2015 complete the authorization using the ICD-9-CM code. We will require no updates even though you will provide some of the services after October 1, 2015. For services that begin October 1, 2015, you should get an authorization using ICD-10-CM codes.
If we submit a claim with ICD-9-CM and ICD-10-CM codes is the authorization valid?
Yes, the authorization will be valid. You are, however, required to file separate claims for services provided October 1, 2015 with ICD-9-CM codes. We will not accept claims with both ICD-9-CM codes and ICD-10-CM codes on the same claim.
Should we normally request the diagnosis code along with the CPT code for authorizations?
You should always request the diagnosis code when getting an authorization.
Do you require medical records for authorizations if we don't know the specific diagnosis code?
We are not changing the authorization process and associated requirements with the implementation of ICD-10-CM. We do accept general diagnosis codes to complete some authorizations today, however, for those services that require a specific diagnosis code to authorize, we may require medical records.
Is a level of care and plan of care the same thing? I work for a physical, occupational and speech therapist who uses plan of care. They are different. The level of care applies to inpatient claims for skilled nursing facilities. The plan of care refers to the treatment plan that is specific to the patient and the services being provided based on their diagnosis/condition.
Will there be a grace period to update the level of care on an authorization?
No. Providers should update the level of care on an authorization as they do today.
Are any medical policies going to change?
We review and update medical policies annually but we updated these policies to include the appropriate ICD-10-CM codes that are applicable to each policy.
Will the changes to the ICD-10 codes affect my contract?
If you are a contracted provider, the changes will affect your contract. We have impacts annually for the Diagnosis Related Group (DRG) groupe changes, and this is not anything new for us to handle. The new ICD‐10 codes will make it slightly more complicated, but the modeling and pay schedule reviews/updates are already a routine part of our annual process.
Will you require new Trading Partner Agreements?
We will not require new Trading Partner Agreements.
How will you communicate to providers any issues with ICD-10-CM implementation?
If something goes wrong will BlueChoice send info/updates or will providers have to go to your website? We will add bulletins to BlueChoiceSC.com on the ICD-10-CM page of our HIPAA Critical Center. Our Provider Services call center will also include any ICD-10-CM announcement via the voice response unit (VRU).
Where can I find the new ICD‐10-CM DX codes?
ICD-10-CM diagnosis and ICD-10 PCS procedure codes and updates are available through the CMS website at www.cms.gov/ICD10.* You can also visit www.ICD10Data.com*, a free medical coding website for current and accurate ICD-10-CM/PCS codes.
Please note: The terms “precertification,” “prior authorization” and “authorization” are used interchangeably but have the same meaning.
*These links lead to third party websites. Those parties are solely responsible for the contents and privacy policies on their sites.