Transition to ICD-10: Role of Clearinghouses

On Oct. 1, 2014, ICD-10 codes will replace ICD-9. The Centers for Medicare & Medicaid Services (CMS) notes practices should not expect clearinghouses to provide the same level of support for the ICD-10 transition as they did for the upgrade from Version 4010 to Version 5010 upgrade.

Because ICD-10 describes a medical diagnosis or hospital inpatient procedure, your practice (or third-party billing/coding service) must select the right codes based on relevant clinical documentation. Thus the key to using ICD-10 successfully will be documenting those elements in the medical record needed to support the specificity of the new codes. Physicians and coding staff should determine which ICD-10 codes they will most use in their practice and become familiar with them and the documentation needed to support them.

Clearinghouses can help by testing that your ICD-10 claims can be processed, identifying the problems that lead to rejections, and providing guidance about how to fix a rejected claim (e.g., you need to include more or different data).

CMS’s Medicare Learning Network has released two revised fact sheets about ICD-10:

Visit the CMS ICD-10 website for the latest news and resources from the agency.

Follow Commercial Payer ICD-10 News 

Keep an eye on your commercial payers’ websites for their ICD-10 news and updates, too:

  • On its ICD-10 webpage, Humana reports it is planning to conduct external end-to-end testing with a select group of early ICD-10 adopters during the second and third quarters of 2013. If you would like to participate in Humana’s testing, email Humana recommends that physicians learn to document the following information to help select the most accurate ICD-10 codes when submitting patient claims:  
    • What caused the injury; how it happened;
    • Where the patient was when the injury occurred;
    • What type of activity the patient was doing when the injury occurred; and
    • If the injury was work-related or could possibly have any other external causes.
  • Visit the Blue Cross and Blue Shield of Texas ICD-10 page to find planning materials, frequently asked questions, and a readiness survey that can help you assess your preparedness for the transition to ICD-10.
  • Aetna reports (PDF) that if a contract includes an ICD-9 diagnosis and/or procedure code as a carve-out, it will recontract those provisions before Oct. 1, 2014, and may start as early as mid-2013. Aetna will not update contracts to use ICD-10 codes; current contract terms support the requirement that physicians bill with HIPAA-compliant code sets as they go into effect (i.e., Oct. 1, 2014, for ICD-10). Read Aetna’s ICD-10 FAQs for information on testing and other details.
  • You can find ICD-10 information for Cigna, including FAQs, on its Cigna for Health Care Professionals website. Under Resources, go to Medical Resources, then to Communications and to HIPAA 5010/ICD-10 Updates.
  • For UnitedHealthcare, to go its ICD-10 website. If you have questions, email 

You’ll also want to bookmark TMA’s ICD-10 resource page for tools, training, tips, and news. Use TMA’s new ICD-10 Transition Toolkit to guide you step by step through learning, planning, organizing, implementing, and analyzing your practice’s ICD-10 transition. It’s available through the TMA Education Center. Watch a four-minute demo.

Published June 11, 2013 

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