ICD-10 Overview

ICD-10-CM/PCS (International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System) consists of two parts:

  1. ICD-10-CM for diagnosis coding
  2. ICD-10-PCS for inpatient procedure coding

ICD-10-CM is for use in all U.S. health care settings. Diagnosis coding under ICD-10-CM uses 3 to 7 digits instead of the 3 to 5 digits used with ICD-9-CM, but the format of the code sets is similar. ICD-10-PCS is for use in U.S. inpatient hospital settings only. ICD-10-PCS uses 7 alphanumeric digits instead of the 3 or 4 numeric digits used under ICD-9-CM procedure coding. Coding under ICD-10-PCS is much more specific and substantially different from ICD-9-CM procedure coding.

The transition to ICD-10 is occurring because ICD-9 produces limited data about patients’ medical conditions and hospital inpatient procedures. ICD-9 is 30 years old, has outdated terms, and is inconsistent with current medical practice. Also, the structure of ICD-9 limits the number of new codes that can be created, and many ICD-9 categories are full. (www.cms.gov/ICD10)

Peach State Health Plan will be ICD-10 compliant by 10/1/2015. Peach State Health Plan will be able to process (send/receive) transactions and perform analytics using ICD-10 diagnosis and procedure codes. Providers must submit claims with codes that align with CMS and state guidelines:

  • Claims may not contain a combination of ICD-9 and ICD-10 codes.
  • Claims must be submitted with ICD-10 codes if dates of service are post-compliance date.
  • Claims must not be submitted with ICD-10 codes prior to compliance date.
  • Outpatient claims with from / through dates that span compliance date must be split.
  • Inpatient claims that span the compliance date must be coded with ICD-10 codes
  • Interim bills for long hospital stays (TOB: 112, 113, 114) are expected to follow the same rules as other claims. If a provider submits a replacement claim (TOB: 117) to cover all interim stays, it is expected that the provider must re-code all diagnoses / procedures to ICD-10 since the replacement claim will have a discharge / through date post-compliance.
  • All first-time claims and adjustments for pre-10/1/2015 service dates must include ICD-9 codes, even if claims are submitted post-10/1/2015. Claims with pre-10/1/2015 service dates can be submitted with ICD-9 codes for as long as contracts and provider manuals specify.

Peach State Health Plan will reimburse claims according to state reimbursement guidelines. Peach State Health Plan plans to adjudicate claims natively in ICD-9 for dates of service prior to 10/1/2015 and natively in ICD-10 for dates of service on and after 10/1/2015, consistent with CMS requirements.

ICD-10 Implementation and Testing Approach

Peach State Health Plan’s ICD-10 implementation approach aligns with CMS guidance and recommended time frames.

The health plan completed its ICD-10 assessment in 2011-2012 and plans to perform HIPAA compliance testing with providers, clearinghouses, vendors and state agencies beginning July, 2013.

Providers that submit claims via EDI or are interested in submitting claims via EDI can test with the health plan. For questions, please contact the EDI service desk at 1-800-225-2573, ext. 25525 or EDIBA@centene.com.

ICD-10 INDUSTRY NEWS AND RESOURCES

Additional information regarding ICD-10 from industry resources can be found here.

CMS Resources

Provider Information and FAQs on ICD-10

CMS ICD-10 Fact Sheet and CMS FAQs

Center for Medicaid & CHIP Services Information Bulletins highlight recent policy guidance and regulations and share Medicaid and CHIP operational and technical information.

Latest News from CMS highlights recent activities and updates from CMS

CMS Implementation Timelines provide detailed timelines and checklists for activities that providers and payers need to execute for ICD-10.

CMS ICD-10 Email Updates provide a source of historical CMS emails related to ICD-10 and the ability for individuals to sign up to receive ongoing email updates.

Other Industry Resources

AHIMA ICD-10

AMA ICD-10

WEDI ICD-10

ICD-10 TRAINING

Details regarding information session opportunities will be coming soon – please continue to check here for updates.

QUESTIONS

FAQs – Providers

For additional questions, please contact Peach State Health Plan’s provider call center representatives at 1-866-874-0633.

FAQs – Clearinghouses

For additional questions, please contact the EDI service desk at 1-800-225-2573, ext. 25525 or EDIBA@centene.com.