ICD-10 Overview

COUNTDOWN TO ICD-10 COMPLIANCE

10/1/2015

ICD-10 OVERVIEW

ICD-10-CM/PCS (International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System) consists of two parts:

  1. ICD-10-CM for diagnosis coding
  2. ICD-10-PCS for inpatient procedure coding

ICD-10-CM is for use in all U.S. health care settings. Diagnosis coding under ICD-10-CM uses 3 to 7 digits instead of the 3 to 5 digits used with ICD-9-CM, but the format of the code sets is similar. ICD-10-PCS is for use in U.S. inpatient hospital settings only. ICD-10-PCS uses 7 alphanumeric digits instead of the 3 or 4 numeric digits used under ICD-9-CM procedure coding. Coding under ICD-10-PCS is much more specific and substantially different from ICD-9-CM procedure coding.

The transition to ICD-10 is occurring because ICD-9 produces limited data about patients’ medical conditions and hospital inpatient procedures. ICD-9 is 30 years old, has outdated terms, and is inconsistent with current medical practice. Also, the structure of ICD-9 limits the number of new codes that can be created, and many ICD-9 categories are full. (www.cms.gov/ICD10)

Centene will be ICD-10 compliant by 10/1/2015. Centene will be able to process (send/receive) transactions and perform analytics using ICD-10 diagnosis and procedure codes. Providers must submit claims with codes that align with CMS and state guidelines:

  • Claims may not contain a combination of ICD-9 and ICD-10 codes.
  • Claims must be submitted with ICD-10 codes if dates of service are post-compliance date.
  • Claims must not be submitted with ICD-10 codes prior to compliance date.
  • Outpatient claims with from / through dates that span compliance date must be split.
  • Inpatient claims that span the compliance date must be coded with ICD-10
  • Interim bills for long hospital stays (TOB: 112, 113, 114) are expected to follow the same rules as other claims. If a provider submits a replacement claim (TOB: 117) to cover all interim stays, it is expected that the provider must re-code all diagnoses / procedures to ICD-10 since the replacement claim will have a discharge / through date post-compliance.
  • All first-time claims and adjustments for pre-10/1/2015 service dates must include ICD-9 codes, even if claims are submitted post-10/1/2015. Claims with pre-10/1/2015 service dates can be submitted with ICD-9 codes for as long as contracts and provider manuals specify.

Centene will reimburse claims according to state reimbursement guidelines. Centene plans to adjudicate claims natively in ICD-9 for dates of service prior to 10/1/2015 and natively in ICD-10 for dates of service on and after 10/1/2015, consistent with CMS requirements.

ICD-10 Implementation and Testing Approach

Centene’s ICD-10 implementation approach aligns with CMS guidance and recommended timeframes.

Centene completed its ICD-10 assessment in 2011-2012 and began HIPAA compliance testing with providers, clearinghouses, vendors and state agencies on July, 2013.

Providers that directly submit claims via EDI or are interested in directly submitting claims via EDI can test with Centene. For questions, please contact the EDI service desk at 1-800-225-2573, ext. 25525 or EDIBA@centene.com.