Frequently Asked ICD-10 Questions

Does the state have to make these changes for its programs or is it exempt? 

All HIPAA-covered entities are required to transition to ICD-10. If a state-run program is a covered 
entity, it is required to transition to ICD-10. 

What lessons have we learned from other nations’ adoption of ICD-10 that will help us in 
our implementation? 
While implementation of ICD-10 in the US is unique, here are some lessons learned elsewhere: 

• Start early to allow time to identify and understand impacts, implement solutions, test and train. (Germany, Australia) 

• Prepare for productivity loss due to coding backlogs, longer turnaround time due to training and assessing performance in the new environment. (Canada, Belgium) 

• Invest in training for coders as well as medical staff. (Germany, France. Australia) 

• Identify and address vendor dependencies. (Germany, Australia) 

What lessons have we learned from US healthcare companies who have started their ICD-
10 programs earlier than most? 
It is important to start ICD-10 programs early. ICD-10 impact assessments and remediation will 
take longer than most remediation efforts previously attempted. Some vendors are discontinuing their ICD-9-based products due to the expense of converting them to ICD-10. You may need to replace certain vendor products a year or more in advance of. the compliance date.

If the choice of using ICD-9 or ICD-10 depends on the Oct. 1, 2015 date, will the date of service or the date of discharge determine which code to use? 

Inpatient claims with discharge dates on or after Oct. 1, 2015, must be coded in their entirety in ICD-10. All outpatient and professional claims with dates of service on or after Oct. 1, 2015, must contain in their entirety ICD-10 diagnosis codes. Please note: Claims may not contain a mixture of ICD-9 and ICD-10 codes. Claims may contain one -- and only one -- code set. Outpatient and Professional claims with service dates spanning the compliance date should be split. 

Do submitters have to “split” the bill if it’s submitted after Oct. 1, 2015? 

Yes. CMS has indicated they want only one code set per claim; i.e., all ICD-9 or all ICD-10. We 
expect our claims to be billed to the same standard. If all claim dates of service are Sept. 30, 2015, or 
earlier, but the claim is submitted after Oct. 1, 2015, ICD-9 should be used. Claims will be rejected 
that contain both ICD-9 and ICD-10 codes. 

Can we submit bills coded in ICD-10 before Oct. 1, 2015? 
Current CMS guidelines require the use of ICD-9 codes until the Oct 1, 2015 effective date. Using 
ICD-10 for claims / services prior to Oct 1, 2015 will violate existing guidelines. We are establishing a 
pilot-test environment that will allow our provider partners the opportunity to test with us in advance of 
the Oct. 1, 2015, date. The details for this process have not been finalized. For updates on our testing 
approach, please visit our ICD-10 webpage. 

Do I need to check with my clearinghouse or payers for their approach for ICD-10 compliance (e.g., conversion, remediation, etc.)?

Yes, most payers have already implemented system and business process changes to accommodate transactions with 
ICD-10 codes and dates of service or discharge dates on or after Oct. 1, 2015, using a “pure” environment (i.e., processing and business rules will be based on the ICD-10 codes.) During an appropriate run-out period (the duration of which has not yet been determined), they will continue to process ICD-9 transactions through their existing environments. 

How will ICD-9 codes be disabled once ICD-10-CM and ICD-10-PCS code sets are in full 
effect? 

There will be late filings and adjustments for several months after Oct. 1, 2015, for 
claims incurred before that date. Claims containing ICD-9 codes with a date of service or discharge 
date of Oct. 1, 2015, or later will be rejected. Please note: Any claim being adjusted must be adjusted 
using the code set in which it was originally filed. 

Will certified medical coders need to have additional training to keep their certification?
Please note that all of your certified medical coders must take a minimum number of ICD-10-specific 
CEUs before the compliance date to maintain their certifications. CEU requirements can vary by 
certifying organization. Contact the certifying organization to get specifics about these requirements. 
CMS is offering informational webinars to provide a general overview of ICD-10. Go to the CMS/ICD-10 
website for details on upcoming sessions. 

For mental health purposes and billing, will the ICD-10 replace the DSM IV -- like CPT 
codes for mental health? 
No. The billing companies will continue using DSM IV codes as they are currently used. The codes used in the 
DSM-IV and the DSM-5 are aligned with ICD codes. The DSM-IV is aligned only with ICD-9 codes. 
The DSM-5, published by the American Psychiatric Association (APA) in May 2013, is aligned with 
both ICD-9 and ICD-10 codes.

You can only use ICD-9 codes until Oct. 1, 2015. Those are the codes used in the DSM-IV. If you are 
using the DSM-5, you will use the ICD-9 codes until Oct. 1, 2015, and then use the ICD-10 codes 
contained within beginning on Oct. 1, 2015. 

How can I get a list of valid ICD-10 diagnosis codes? 
File downloads can be found on the CMS website at: 
http://www.cms.gov/Medicare/Coding/ICD10/index.html. To purchase ICD-10 coding books or 
subscribe to on-line coding tools, you can conduct an internet search for vendors that offer electronic 
coding, billing and reimbursement products and training resources. Additional information is also 
available on the CMS website. 

Will there be changes to the guide regarding what is expected on the paper claim forms (CMS-1500 and CMS-1450/UB-04)? 

The National Uniform Claim Committee (NUCC) has released an updated version of the CMS-1500 form that will support ICD-10 codes. For more information about the CMS-1500 form, visit the NUCC at nucc.org. 

The National Uniform Billing Committee (NUBC) is responsible for the CMS-1450 (UB-04) form on 
behalf of CMS. We do not know the extent of changes expected for the CMS-1540 (UB-04) form, if 
any. For more information, visit the NUBC at nubc.org. 

How does implementation of ICD-10 impact providers filing paper claims? 
The ICD-10 code set must be used on all claims – paper or electronic -- with dates of service on or 
after Oct.1, 2014, and inpatient claims with a date of discharge on or after Oct.1, 2015. Likewise, we 
will reject paper claims that contain ICD-10 codes with dates of service and discharge date prior to 
October 1, 2014. The media (paper or electronic) used to submit the claim will not impact the code 
set used on the claim. ICD-10 MUST be used, based on the above criteria. 

We currently submit paper claims (CMS 1500 forms) and use ICD-9 codes. Will we have to 
use ICD-10 on paper claims? 
Yes. On and after Oct. 1, 2015, all electronic and paper claim submissions will be coded in ICD-10. 

Can I submit ICD-9 claims after Oct. 1, 2014, for service dates before Oct. 1, 2015?

Will claims submitted in ICD-9 before Oct. 1, 2015, and then resubmitted afterward need to be 
converted to ICD-10?

Use of ICD-10 is service-date driven. So inpatient claims with discharge dates on or after Oct. 1, 
2015, and outpatient or professional claims with dates of services on or after Oct. 1, 2015, must be 
coded using the ICD-10 code set. Resubmissions/adjustments to previously filed claims must be 
submitted in the same code set used in t23. 
 
Will CPT codes change or continue to be used as in the past?

CPT codes will not change and will still be used on outpatient and professional claims. ICD-10 
procedure codes will only be used on inpatient claims. 

Our billing software vendor indicates they will be ready for these transitions. What can I do 
in the meantime, besides train for ICD-10 coding? 

Ask your billing software vendor for a detailed schedule of deliverables and begin preparing to test 
implementation of the modified software at your location. Be sure to verify the following: 

• The vendor is addressing the ICD-10 upgrades 
• The number and schedule of planned ICD-10 software releases 
• Their ICD-10 conversion plan accommodates your clearinghouse testing schedule 
• Any related costs to your organization 

Which version of the ICD-10 code book should I use? 

There are numerous versions of ICD-10 coding books available in the market today. At this time, we 
cannot recommend a specific book; however, we do recommend use of ICD-10 code books 
published in the US. To maintain consistency in your coding manuals, you may want to contact the 
same sources you relied on for ICD-9 manuals and coding tools.

For more tips on talking to vendors go to: Talking to Vendors at 
https://www.cms.gov/ICD10/Downloads/ICD10TalkingtoVendorforMedicalPractices20100409.pdf 

When will payers be ready to accept test transactions from my practice?

You will need to check with all of your payers to find out that date. CMS Medicare is already scheduling one week a month where they will accept test claims in ICD-10. Check with the MAC website for the schedule of these testing weeks.

Do you anticipate any changes in policies or delays in payments to result from the switch 

to ICD-10? 
 
Overall, payers have updated their policies to refer to the ICD-10 code set, but no major changes to 
policies have been implemented. Delays in payments are not anticipated for those providers 
transitioning to ICD-10 by Oct. 1, 2015. 
 
On and after Oct. 1, 2015, do we submit Worker’s Comp claims in ICD-9 or ICD-10?

According to the US Department of Health and Human Services (HHS), Worker's Comp is NOT 
considered a Covered Entity under HIPAA. Therefore, it is NOT subject to the Final Rule regarding 
ICD-10. But HHS strongly encourages converting to the new ICD-10 code set. 
Here's a link for more information: 
http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/workerscomp.html 

How can we test my ICD-10 coded claims before the compliance date of Oct. 1, 2015? 
Some payers are allowing the practices to submit test claims using ICD-10. You should check with  your payers  to see what their policy is. CMS Medicare is scheduling one week per month for doctors to submit text claims using ICD-10 codes. Go to the Medicare Administrative Contractors website at  Contact MAC   to see when these weeks are scheduled.

What if I am submitting a claim before 10/1/15 for pre-approval for a procedure to be done after 10/1/15? Does that claim need to be in ICD-10 coding?

Yes, that claim must be submitted with diagnoses in ICD-10 coding.