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 ICD10inquiries@humana.com. 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 ICD10questions@uhc.com 

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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