Home Health ICD-9/ICD-10 Alert

2011 brings the last major ICD-9 update.

If the coming transition to ICD-10 has you brimming with logistical questions, you're not alone. Representatives from the Centers for Medicare & Medicaid Services shed light on several related issues during the agency's May "ICD-10 National Provider Teleconference," and we've broken down some of the major answers for you.

Question 1: How will CMS handle claims that span from before Oct. 1, 2013 through dates after Oct. 1, 2013? Should the practitioner use ICD-9 or ICD-10 codes for these claims?

Answer: CMS is mulling how to handle this situation, but hasn't yet arrived at a firm decision. "We are getting very close to finalizing our decision for all claim types, including professional claims, supplier claims, and the various types of institutional claims," said CMS's Sarah Shirey-Losso during the call. "Some claims will continue to use the discharge date, some will use the 'from' date, and some may be required to be split," she said.

Stay tuned: CMS is currently working on a final decision, which the agency will issue in a "Change Request" document this summer.

Date of service issue: If, however, you submit a claim for a single date of service, you'll submit ICD-9 codes for dates of service through Sept. 30, 2013, and ICD-10 codes for dates of service Oct. 1, 2013 and thereafter.

For instance: If you send in a claim on Oct. 15, 2013, but the date of service is Sept. 1, 2013, you'll still use ICD-9 codes.

Question 2: What are the penalties for entities that are covered under HIPAA who choose not to use ICD-10 codes as of Oct. 1, 2013?

Answer: Your claims will be denied -- and you technically could face fines since use of the ICD-10 codes falls under the HIPAA transaction code set regulations, CMS reps noted.

Denials: "From a practical standpoint, as of service dates of Oct. 1, 2013, if you don't use ICD-10 codes, most likely your claims will be returned and you will be asked to transition them to ICD-10," said CMS's Denise Buenning, MsM.

Fines: "The penalties are the same penalties that any HIPAA entity would be subject to," Buenning noted. "I think most of you are familiar with the ongoing HIPAA transaction codeset penalty that calls for a maximum of $25,000 per covered entity per year, but the HITECH legislation of last year actually upped those transaction and codeset penalties, and they can be as much as $1.5 million per entity per year. So obviously it behooves everybody -- Medicare and Medicaid inclusive -- to make sure we are compliant with these ICD-10 codes by the Oct. 1, 2013 date," she added.

Question 3: When will CMS finalize the ICD-10 code set?

Answer: As of this October, you'll see an ICD-10 code set that's pretty close to how the final will look.

"The final version will be the one that will be implemented in FY 2014 [issued on Oct. 1, 2013]," said CMS's Pat Brooks, RHIA. "So what we're doing each year we update it, we're telling you the current version we're working from. We will have the last major update in FY 2012 [which will be implemented Oct. 1, 2011], but we're warning you that we could add some more codes because of new technology and new procedures, but each year has a version and that's the official version for the current year."

Freeze: To help ease the transition to ICD-10 CMS, will be implementing a partial code freeze on October 1, 2011. This is the last day for regular updates to both the ICD-9 and ICD-10 code sets.

For October 1, 2012, only limited code updates will be made to both the ICD-9-CM and ICD-10 code sets to keep up with new technology and diseases. Come October 1, 2013, there will be no new ICD-9-CM updates because ICD-10 will be the current standard.

In preparation for the ICD-10 transition, CMS has made ICD-9 to ICD-10 General Equivalence Mappings (GEMs) available online. The GEMs provide a crosswalk between ICD-9 and ICD-10 codes so you can look up an ICD-9 code and find the most appropriate corresponding ICD-10 match.

While you'll still need to learn the new ICD-10 codes, the GEMs can give you a starting point in understanding the differences between the ICD-9 codes and the ICD-10 codes for a given condition.

The 2011 GEMs are posted to the CMS ICD-10 website visit www.cms.gov/ICD10 for the latest news on the upcoming transition.