How ICD-10 Affects Your Claims

There’s no doubt that the ICD-10 transition requires a huge shift in processes. But it’s not only your coding methodology that’ll change; your claims are going to look a little different as well. Here’s how ICD-10 affects your claims:

HCFA Forms are Ready

Wondering whether your beloved CMS 1500 forms are ready for ICD-10? Good news: the form was updated several years ago to account for ICD-10. This “new” form allows for up to 12 diagnosis codes—and you might just need all of those spots to accurately and completely describe a patient’s condition.

CPT Codes will Stick Around

If you’re an outpatient provider who uses CPT codes, you won’t need to change your procedural coding. You’ll continue to bill for the services you provide using the same codes you do now (e.g., 97001, 97110, and 97140). However, keep in mind that if you use superbills, you will need to update those to include ICD-10 codes. Finally, ICD-10 won’t impact the way you currently use any CPT-related modifiers (like KX or modifier 59).

One Service Line Allows for Four Codes

Remember the 12 available spots on the new HCFA forms? While you can submit up to 12 diagnosis codes on a single claim form, only four of those will map to a specific CPT code. That’s because the form only contains four diagnosis pointers per line. This is something that won’t change with the ICD-10 transition. Still, it’s important to include as many codes as you believe are relevant to your treatment.

Code Order Matters

When you’re dealing with multiple codes, you want to list them in order of importance. The first-listed code will be your primary code, which means it’s the code that most strongly supports the medical necessity of your treatment. Proving medical necessity is crucial when it comes to ICD-10; check out this blog post to learn more.

There’s no Minimum Number of Codes

For a claim to process correctly, it must contain at least one code. The number of additional codes you include is up to you. If you, as the clinical expert, believe one code accurately and fully describes a patient’s condition, then by all means, submit only one code. Beyond that, there’s no minimum of codes required on each claim.

Dual-Coding is a No-No

The transition to ICD-10 is determined by date of service. That means all claims with dates of service on or before September 30 must contain only ICD-9 codes, whereas all claims with dates of service on or after October 1 must contain only ICD-10 codes. The two can never appear together on the same claim. So, in order to avoid a dual-coding disaster, you may need to split your claims. Each payer will have its own claim-splitting requirements, so it’s important to check with that payer first before you determine how you’ll separate claims that span the transition date.

That said, some non-HIPAA-covered entities (e.g., workers’ compensation, and auto insurance) may not make the transition. So, you’ll need to continue to submit ICD-9 codes on the claims for those payers. We strongly suggest contacting your non-HIPAA covered payers individually to verify whether they plan to make the transition. Furthermore, as Lauren Milligan explains in this blog post, “Sometimes, you’ll see patients whose primary and secondary insurances require different code sets. In these cases, because you should include only ICD-9 codes on claims for payers who did not make the switch to ICD-10, you’ll need to split the claim and send each piece to the appropriate payer.”

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With these details in mind, give yourself a head-start by getting caught up on all of your billing prior to October 1. It may not be the easiest task, but it’ll save you a lot of headaches as you tackle the transition. And although not much will change in terms of how you complete and submit claims, you’ll be plenty busy adjusting your processes elsewhere. With the transition right around the corner, what are you doing to prepare?