Pediatric Coding Alert

Hint: Keep on using your modifiers the same way after Oct. 1

With the ICD-10 implementation date just a few months away, you’re certain to have a few questions about the new diagnosis system. We’ve compiled questions from three pediatric sources—along with the answers that will help you stay on track to ICD-10 compliance.

Modifiers Aren’t Impacted

Question 1: Will the upcoming ICD-10 implementation have any effect on our usage of the 59 modifier or our other modifiers?

Answer: You’ll still be able to report modifier 59 (Distinct procedural service) and all other modifiers that are billed with CPT® codes. The ICD-10 code set will affect how you report diagnosis codes, but does not influence your CPT® code or modifier selection.

“Note that CPT® will still be the code set to use for all physician/provider-based professional services,” the American Academy of Pediatrics says in its ICD-10-CM Frequently Asked Questions document. “The implementation of ICD-10-CM will not impact how you report CPT® codes, including proper modifier placement.”

Insurers Will Differ on Pre-Authorization Diagnoses

Question 2: Suppose we submit a preauthorization on Sept. 25 using ICD-9 codes. The insurer usually takes two weeks to get back to us with pre-authorization approvals or denials. Will they accept my request or should I submit it using ICD-10 codes instead, since the approval process will likely cross into the Oct. 1 implementation date? 

Answer: Each insurer will probably handle this differently, but some payers have already posted answers to this on their websites. For instance, Humana notes that it will issue its authorizations based on your request date. “If an authorization is requested on or before the compliance date, and the date of service is on or after Oct. 1, 2015 providers should submit an ICD-10 code,” the insurer says on its site. “If the authorization is requested after the compliance date, the ICD-10 code will be required. Humana will begin accepting ICD-10 codes for authorizations and referrals on July 1, 2015 and will not accept any ICD-9 authorization codes after Oct. 1, 2016.”

Check With Referral Sources

Question 3: We deal with a lot of small community practitioners that may not have the resources to understand what the ICD-10 implementation entails. How should we make sure their referrals to us are ICD-10 compliant? 

Answer: According to Blue Cross Blue Shield of Tennessee, you should create a “dry run” with these practitioners ahead of time to make sure everyone is on the same ICD-10 page. 

“Conduct surveys with your community providers to assess their understanding and readiness of ICD-10,” the insurer says. “Conduct testing of normal modes of communication and include community providers in your training sessions. Provide explanations of the impact of the disruption if they are not compliant.”