ICD-10 FAQs

Q. Does the new ICD-10 requirement apply to me?

A. All HIPAA Covered Entities must begin using the new ICD-10 code sets on October 1, 2015.

Q. What is the time frame for implementing ICD-10?

A. The Pennsylvania Department of Human Services has completed the initial assessments of the Medicaid Management Information System (MMIS) and is on target for the October 1, 2015 implementation of the ICD-10 code sets. The ICD-10 code sets will not be accepted until that date.

Q. Who is affected by the ICD-10 implementation?

A. All Providers and vendors that use ICD-9 codes will be affected and therefore need to transition to ICD-10 on October 1, 2015, the established ICD-10 compliance date.

Q. How will claims be handled for secondary payers who are not accepting ICD-10 codes, however the primary payer does and the claim is submitted with ICD-10 codes (ex: Medicare crossover claims). Also, the reverse, how will claims be handled for a secondary payer who is accepting ICD-10 codes, however the primary payer does not and the claim is submitted with ICD-9 codes?

A. All HIPAA Covered Entities must begin using the new ICD-10 code sets on October 1, 2015. Claims submitted with dates of service on or after October 1, 2015 not containing ICD-10 codes will deny due to non-compliance.

Q. Does Pennsylvania Medicaid have a dedicated person or team that will handle the ICD-10 transition?

A. Yes, the Department of Human Services has in place a dedicated team comprised of Project Managers and technical staff, all with the intricate knowledge of the PROMISe™ system and the specific requirements of ICD-10 requirements.

Q. Will you be ready to accept ICD-10 codes by 10/01/15?

A. Yes, the Pennsylvania Medicaid MMIS will be ready to accept and process claims with ICD-10 diagnosis and inpatient procedure codes effective with dates of service or dates of discharge on 10/1/2015. In addition, all Physical Health Managed Care Organizations, who contract with the Pennsylvania Department of Human Services, continue to report that they are progressing and will be ready for a 10/1/2015 implementation.

Q. Will there be a grace period for accepting ICD-9 codes for dates of service on or after 10/1/15?

A. No, HHS has no plans to extend the compliance date for implementation of ICD-10-CM/PCS. Therefore, covered entities should plan to complete the steps required to implement ICD-10-CM/PCS on October 1, 2015.

Q. Who will be responsible for making sure Providers use the correct codes?

A. The responsibility of reporting accurate codes lies with the Providers. It is recommended that Providers become familiar with the code sets and guidelines to ensure the correct assignment of ICD-10 codes.

Q. What should Providers do to assess/prepare for ICD-10 impact to our computer systems?

A. Review your file layouts and storage, making certain your fields will accommodate the new code length. Contact your software vendor to resolve any concerns.

Familiarize yourself with the ICD-10 code set and coding guidelines to help assess the impact on your system.

Q. Will the implementation of ICD-10 be based on date of service or date of receipt for claims processing?

A. Claims will be processed based on date of service: date of service for outpatient claims and date of discharge for inpatient facility claims. In addition, all claims received on or after the ICD-10 compliance date will require a version indicator (ICD-9 = 9 or ICD-10 = 0). The ICD indicator is located in block 21 of the CMS 1500 (02/12) draft version.

Q. Will you accept ICD-10 codes for dates of service before 10/1/15?

A. No. The Department will not be able to accept or process claims using ICD-10 codes until the October 1, 2015 compliance date.

Q. Will you provide a cross walk that shows the ICD-9 code and the ICD-10 code it maps to?

A. No, the Department will not be providing an ICD-9 to ICD-10 coding crosswalk. Please visit the CMS website at https://www.cms.gov/Medicare/Coding/ICD10/Medicare-Fee-For-Service-Provider-Resources.html#Coding for additional information and available free online tools on how to translate ICD-9 codes into ICD-10 codes and ICD-10 codes into ICD-9.

Q. Will there be re-enrollment required due to the ICD-10 mandate?

A. No, there are no re-enrollment requirements due to the ICD-10 mandate.

Q. What is the estimated date that the paid claim files utilized by HMS will be able to accept ICD-10 codes?

A. The Department will comply with the CMS mandated date.

Q. What is your contingency plan if your system is not ready on October 1, 2015?

A. The Department is treating October 1, 2015 as a firm date for ICD-10 implementation.

Q. Will there be any transmission/connection changes or report changes to prepare for the ICD-10 mandate?

A. The Department expects no changes to the EDI transmission/connection process or the transaction reports. There will be some changes to reports that result from claim processing (e.g., Remittance Advice).

Q. Will you be able to provide the key milestone dates for the ICD-10 compatible application/solution/interface, including dates for development, internal testing, external testing, training, and production implementation? Submit a project work plan (MS Project, Excel, GANTT, PowerPoint, etc.) if available.

A. The Department will coordinate with CMS for the ICD-10 implementation, as deemed appropriate.

Q. Are providers required to be certified with the Department in order to send/submit ICD-10 claims?

A. All providers/clearinghouses were required to be recertified as part of the ANSI X12 v5010 implementation. An ICD-10 certification will not be required.

Q. When will the Department have the ICD-10 edit requirements available?

A. The Department will post all Error Status Codes (ESCs) associated with ICD-10 on the DHS website prior to October 1, 2015.

Q. Will testing be voluntary, mandatory, or even available?

A. The Department will be working with a limited number of selected providers for ICD-10 testing. If you are a new submitter, please refer to the following link for steps to be taken to be certified to submit transactions to PROMISe™. http://www.DHS.state.pa.us/provider/promise/certification/index.htm

Q. What type(s) of testing will the Department support for ICD-10?

A. The Department will be working with a limited number of selected providers for ICD-10 testing. If you are a new submitter, please refer to the following link for steps to be taken to be certified to submit transactions to PROMISe™. http://www.DHS.state.pa.us/provider/promise/certification/index.htm

Q. Will the Department be allowing end-to-end provider testing with all providers and trading partners?

A. The Department will be working with a limited number of selected providers for ICD-10 testing. If you are a new submitter, please refer to the following link for steps to be taken to be certified to submit transactions to PROMISe™. http://www.DHS.state.pa.us/provider/promise/certification/index.htm

Q. If testing is required, what is the earliest date you will begin accepting ICD-10 test files?

A. The Department will be working with a limited number of selected providers for ICD-10 testing. If you are a new submitter, please refer to the following link for steps to be taken to be certified to submit transactions to PROMISe™. http://www.DHS.state.pa.us/provider/promise/certification/index.htm

Q. Will the Department be notifying providers directly that they are selected to test with the Department?

A. The Department will be working with a limited number of selected providers for ICD-10 testing. If you are a new submitter, please refer to the following link for steps to be taken to be certified to submit transactions to PROMISe™. http://www.DHS.state.pa.us/provider/promise/certification/index.htm

Q. Do providers need to contact the Department to be approved to submit test files?

A. The Department will be working with a limited number of selected providers for ICD-10 testing. If you are a new submitter, please refer to the following link for steps to be taken to be certified to submit transactions to PROMISe™. http://www.DHS.state.pa.us/provider/promise/certification/index.htm

Q. Will you allow optional testing by providers who wish to submit test claims and receive a test 835 or EOB indicating how the claims would have been paid?

A. The Department will be working with a limited number of selected providers for ICD-10 testing. If you are a new submitter, please refer to the following link for steps to be taken to be certified to submit transactions to PROMISe™. http://www.DHS.state.pa.us/provider/promise/certification/index.htm

Q. Will MCOs providing Maternity Care files be required to test with the Department?

A. Maternity care files testing will be required. Testing plans will be discussed at an upcoming MCO ICD-10 monthly meeting.

Q. When will policies and/or regulations be updated with ICD-10 codes and available for public viewing?

A. The Department will have the Provider Handbooks and Billing Guides updated and available on the website on October 1, 2015.

Q. What ICD-10 Date validation criteria will the Department follow?

A. The Department will follow all CMS rules for ICD-10 date validation.

Q. Will the Department be performing ICD-10 Code set/Date validation?

A. The Department will be performing ICD-10 production validation.

Q. Will the Department crosswalk any codes?

A. No. The Department will not be providing an ICD-9 to ICD-10 coding crosswalk. Please visit the CMS website at https://www.cms.gov/Medicare/Coding/ICD10/Medicare-Fee-For-Service-Provider-Resources.html#Coding for additional information and available free online tools on how to translate ICD-9 codes into ICD-10 codes and ICD-10 codes into ICD-9.

Q. How will PROMISe handle the transition to ICD-10?

A. The Department will make all necessary changes in PROMISe™ to support the ICD-10 requirements.

Q. Will there be any 837 file output requirements associated with the new code set?

A. The 837 file layout was established under the ANSI X12 v5010 upgrade. There are no additional format/structure changes associated with ICD-10.

Q. Is there an ICD-10 CME requirement for physicians in Pennsylvania?

A. All certified coders regardless of their occupation/status must test for ICD-10 to remain a certified coder.

Q. Will the Department enforce ICD-10 codes on 10/1/2015?

A. Yes, the Department will comply with the CMS mandated date of 10/1/2015.

Q. Does Pennsylvania Medicaid have a website dedicated to ICD-10 with updated documents? 

A. Please visit the DHS website often for up-to-date information on the Department's progress on this initiative. The dedicated web page includes general ICD-10 information, Fact Sheets, FAQs, and much more.
http://www.DHS.state.pa.us/provider/icd10information/P_012571

Q. Do you have any ICD-10 Information available at this time?

A. Please visit the DHS website often for up-to-date information on the Department's progress on this initiative. The dedicate web page includes general ICD-10 information, Fact Sheets, FAQs, and much more.
http://www.DHS.state.pa.us/provider/icd10information/P_012571

Q. What is the best way to get additional ICD-10 information? Is there a mailing list, a special section on your website or a separate contact?

A. To promote the exchange of ICD-10 information, the Department has established a dedicated ICD 10 Webpage, an ICD-10 mailbox, and an ICD-10 Listserv on the Pennsylvania Department of Human Services website. To access the ICD-10 webpage, click here.

Q. If a claim has an ICD-9 code and a date of service after 10/1/15, will it be a claim level rejection, a file level rejection, or a reimbursement denial?

A. Claims submitted with ICD-9 codes on or after October 1, 2015 will result in a denied claim at the claim processing level. However, a single claim with such an error when submitted as part of a batch will result in a batch (file) rejection at the EDI translator before it reaches PROMISe™.

Q. If an authorization was issued specific to an ICD-9 code how will the claim adjudication be handled after 10/1/15 2015?

A. Authorizations for dates of service and/or dates of discharge prior to October 1, 2015 will require ICD-9 codes on the claims submitted. However, authorizations for dates of service and/or dates of discharge on or after October 1, 2015 will require ICD-10 codes on claims submitted.

Q. Will the provider be required to continue to bill with ICD-9 until the term date of the existing authorization?

A. No, the provider is required to bill the appropriate code based on date of service and/or date of discharge. Prior to October 1, 2015, the provider should submit claims using ICD-9. After October 1, 2015, the provider should submit claims using ICD-10.

Q. Will the provider be able to bill using the ICD-10 code and will the payer validate and map back to the authorized ICD-9 code?

A. The provider will be required to bill using the ICD-10 codes for dates of service and/or dates of discharge on or after October 1, 2015 based on the services provided.

Q. If a new authorization is required to include the ICD-10 codes, is the payer going to relax their policy and allow retro authorizations? If so, for how long?

A. A new authorization will not be required on previous authorizations submitted with ICD-9 codes.

Q. Correct coding guidelines for ICD-10 state that “encounter for” codes should be the primary diagnosis on the claim with the medical diagnosis reported as the secondary. For example, if a patient with breast cancer receives chemo, should the claim be coded for chemo first and the cancer diagnosis second?

A. Providers should submit claims with the diagnosis code that matches the service provided.

Q. Will you accept claims with ICD-9 codes and claims with ICD-10 codes in the same file?

A. Yes, a batch (file) may contain both ICD-9 and ICD-10 claims. A single claim may not contain both ICD-9 and ICD-10 codes.

Q. Will you still support ICD-9 codes for corrected, resubmitted, run-out claims, and secondary (COB) and subrogation claims?

A. ICD-9 codes may be submitted for dates of service rendered prior to 10/1/2015.

Q. Will the system accommodate both ICD-9-CM and ICD-10 CM/PCS codes in a dual-use mode?

A. The system will accommodate both ICD-9 and ICD-10 codes used in accordance with applicable policy/regulations. A single claim cannot contain both ICD-9 and ICD-10 codes. Claims with mixed code sets will deny.

Q. If a provider submits a claim after 10/1/2015 with a date of service prior to 10/1/2015 which contains an ICD-9 code will PA Medical Assistance reject the claim, pay the claim, or return the claim to the provider?

A. Claims will be processed based on the date of service for outpatient claims and date of discharge for inpatient institutional claims. In addition, all claims received on or after the ICD-10 compliance date will require a version indicator (ICD-9 = 9 and ICD-10 = 0). The ICD type indicator is located in block 21 of the CMS 1500 (02/12) claim form.

Q. Will PA Medical Assistance accept hospital inpatient claims with ICD-10 codes on 10/1/15 and then map them back to ICD-9 codes for claim adjudication?

A. No, the Department will not be mapping ICD-10 codes back to ICD-9 codes for claim adjudication.

Q. How will the Department handle claims from a provider’s office who cannot convert to ICD-10 by 10/1/2015? Will you be using the GEM’s file?

A. All HIPAA covered entities must begin using the new ICD-10 code sets on October 1, 2015. Claims submitted with dates of service and/or dates of discharge on or after October 1, 2015 not containing ICD-10 codes will deny due to non-compliance.

Q. What ICD Grouper Version will the Department of Human Services be using at the time of the ICD-10 implementation?

A. The Department will implement ICD-10 APR-DRG version 31 prior to October 1, 2015.

Q. When will the DHS approved/billable ICD-10 listing for Behavioral Health Services be issued to the BH_MCO’s?

A. We do not yet have a specific date by which the Department of Human Service’s Office of Mental Health and Substance Abuse Services (OMHSAS) will communicate the allowable ICD-10 codes to its behavioral health business partners. The information will be communicated by email listserv and also posted to the OMHSAS site on the DHS Intranet.

For questions and/or to provide feedback about ICD-10 implementation, please email RA-pwomapicd10@pa.gov

Join our ICD-10 Listserv.