Archive for ICD-10

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CMS and AMA Make ICD-10 “Family” Clarification

Medicare will reimburse claims with ICD-10 codes as long as they are in the correct code "family" for 12 months.

Clarifying Questions and Answers Related to the July 6, 2015 CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities

Question 1:

When will the ICD-10 Ombudsman be in place?

Answer 1:

The Ombudsman will be in place by October 1, 2015.

Question 2:

Does the Guidance mean there is a delay in ICD-10 implementation?

Answer 2:

No. The CMS/AMA Guidance does not mean there is a delay in the implementation of the ICD-10 code set requirement for Medicare or any other organization. Medicare claims with a date of service on or after October 1, 2015, will be rejected if they do not contain a valid ICD-10 code. The Medicare claims processing systems do not have the capability to accept ICD-9 codes for dates of service after September 30, 2015 or accept claims that contain both ICD-9 and ICD-10 codes for any dates of service. Submitters should follow existing procedures for correcting and resubmitting rejected claims.

Question 3:

What is a valid ICD-10 code?

Answer 3:

ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity. A three-character code is to be used only if it is not further subdivided. To be valid, a code must be coded to the full number of characters required for that code, including the 7th character, if applicable. Many people use the term billable codes to mean valid codes. For example, E10 (Type 1 diabetes mellitus), is a category title that includes a number of specific ICD-10-CM codes for type 1 diabetes. Examples of valid codes within category E10 include E10.21 (Type 1 diabetes mellitus with diabetic nephropathy) which contains five characters and code E10.9 (Type 1 diabetes mellitus without complications) which contains four characters.

A complete list of the 2016 ICD-10-CM valid codes and code titles is posted on the CMS website at http://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html. The codes are listed in tabular order (the order found in the ICD-10-CM code book). This list should assist providers who are unsure as to whether additional characters are needed, such as the addition of a 7th character in order to arrive at a valid code.

Question 4: What should I do if my claim is rejected? Will I know whether it was rejected because it is not a valid code versus denied due to a lack of specificity required for a NCD or LCD or other claim edit?

Answer 4:

Yes, submitters will know that it was rejected because it was not a valid code versus a denial for lack of specificity required for a NCD or LCD or other claim edit. Submitters should follow existing procedures for correcting and resubmitting rejected claims and issues related to denied claims.

Question 5:

What is meant by a family of codes?

Answer 5:

“Family of codes” is the same as the ICD-10 three-character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved. Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters. One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid.

Question 6:

Does the recent Guidance mean that no claims will be denied if they are submitted with an ICD-10 code that is not at the maximum level of specificity?

Answer 6:

In certain circumstances, a claim may be denied because the ICD-10 code is not consistent with an applicable policy, such as Local Coverage Determinations or National Coverage Determinations. (See Question 7 for more information about this). This reflects the fact that current automated claims processing edits are not being modified as a result of the guidance.

In addition, the ICD-10 code on a claim must be a valid ICD-10 code. If the submitted code is not recognized as a valid code, the claim will be rejected. The physician can resubmit the claims with a valid code.

Question 7:

National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) often indicate specific diagnosis codes are required. Does the recent Guidance mean the published NCDs and LCDs will be changed to include families of codes rather than specific codes?

Answer 7:

No. As stated in the CMS’ Guidance, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family of codes. The Medicare review contractors include the Medicare Administrative Contractors, the Recovery Auditors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor.

As such, the recent Guidance does not change the coding specificity required by the NCDs and LCDs. Coverage policies that currently require a specific diagnosis under ICD-9 will continue to require a specific diagnosis under ICD-10. It is important to note that these policies will require no greater specificity in ICD-10 than was required in ICD-9, with the exception of laterality, which does not exist in ICD-9. LCDs and NCDs that contain ICD-10 codes for right side, left side, or bilateral do not allow for unspecified side. The NCDs and LCDs are publicly available and can be found at http://www.cms.gov/medicare-coverage-database/.

Question 8:

Are technical component (TC) only and global claims included in this same CMS/AMA guidance because they are paid under the Part B physician fee schedule?

Answer 8:

Yes, all services paid under the Medicare Fee-for-Service Part B physician fee schedule are covered by the guidance.

Question 9:

Do the ICD-10 audit and quality program flexibilities extend to Medicare fee-for-service prior authorization requests?

Answer 9:

No, the audit and quality program flexibilities only pertain to post payment reviews. ICD-10 codes with the correct level of specificity will be required for prepayment reviews and prior authorization requests.

MEDICAID

Question 10:

If a Medicare paid claim is crossed over to Medicaid for a dual-eligible beneficiary, is Medicaid required to pay the claim?

Answer 10:

State Medicaid programs are required to process submitted claims that include ICD-10 codes for services furnished on or after October 1 in a timely manner. Claims processing verifies that the individual is eligible, the claimed service is covered, and that all administrative requirements for a Medicaid claim have been met. If these tests are met, payment can be made, taking into account the amount paid or payable by Medicare. Consistent with those processes, Medicaid can deny claims based on system edits that indicate that a diagnosis code is not valid.

Question 11:

Does this added ICD-10 flexibility regarding audits only apply to Medicare?

Answer 11:

The official Guidance only applies to Medicare fee-for-service claims from physician or other practitioner claims billed under the Medicare Fee-for-Service Part B physician fee schedule. This Guidance does not apply to claims submitted for beneficiaries with Medicaid coverage, either primary or secondary.

Question 12:

Will CMS permit state Medicaid agencies to issue interim payments to providers unable to submit a claim using valid, billable ICD-10 codes?

Answer 12:

Federal matching funding will not be available for provider payments that are not processed through a compliant MMIS and supported by valid, billable ICD-10 codes.

OTHER PAYERS

Question 13:

Will the commercial payers observe the one-year period of claims payment review leniency for ICD-10 codes that are from the appropriate family of codes?

Answer 13:

The official Guidance only applies to Medicare fee-for-service claims from physician or other practitioner claims billed under the Medicare Fee-for-Service Part B physician fee schedule. Each commercial payer will have to determine whether it will offer similar audit flexibilities.

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What Tools Will You Need for the ICD-10 Transition? Q & A with Swiftaudit

Learn How to Crosswalk Your ICD-9s to ICD-10s

 

 

October 1, 2015 is a date that looms large for everyone involved in the operational and financial functions of any medical practice. At the time of this post’s publishing, practice administrators, managers, billers and coders have less than three months to make sure they have the processes and systems in place to minimize the business disruption from the changeover. As we talked to clients and readers about the challenges they are facing with the ICD-10 upgrade over the past several years, we started looking for tools that could help practices ease the transition.

One tool really stood out more than the others. Swiftaudit Search is a web-based coding conversion and look-up tool for both ICD-9 and ICD-10 code sets that we strongly endorse for its ability to supercharge ICD-10 coding, audits and upgrade preparations. We’ve been using Swiftaudit Search here at Manage My Practice for months now and we are very excited about how it can help our readers and clients.

We sat down with the creators of Swiftaudit Search, Chicago’s SpringSoft to ask them more about how practices can prepare for the upgrade.

Manage My Practice: Tell us about SpringSoft and how you starting working in the healthcare software market.

SpringSoft: We’ve provided software to the healthcare coding and compliance market since 1995. Our first product was E&M Coder™ for evaluation and management coding and audits. It all started when a few forward thinking doctors told us “the auditors are coming.” Given our background in corporate business systems, our research provided a couple of interesting observations at that time. One – physician offices had few easy to use software applications. Two – from a business point of view, physician offices needed help with coding and compliance. So we tackled a challenging little-understood coding issue in 1994 – the introduction of evaluation and management codes.

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Manage My Practice: Your product that is designed for medical coding has gone through several iterations since the ICD-10 mandate was first announced – how did your product evolve?

SpringSoft: We started designing what is now Swiftaudit Pro several years ago. As we designed the coding components, we realized that our ICD-10 Search features would benefit physicians during the transition to ICD-10. Again, we took on a daunting challenge. We knew we had to design an intuitive ICD-10 Search Feature. Once you find a group of codes, the next problem was to be present all of the ICD-10 coding information to describe the patient’s health condition. So now, as Swiftaudit evolves, our goal is to present the ICD-10 coding guidelines in a quick and straightforward way.

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Manage My Practice: We‘ve seen a wide variety of encoder-type products designed for hospitals and large organizations, and some designed for billing companies and consultants. What target market is the best fit for your products and why?

SpringSoft: Currently, we see our market as physician offices. Hospital and large organization coding systems have to address ‘packet’ coding, such as DRG (Diagnosis Related Groups) and HCCs (Hierarchical Condition Categories). Hospitals and large organizations will benefit from our auditing platform – SwiftAudit Pro. Providers who need to code ICD-10s will benefit from Swiftaudit Search. They can use our product to learn how code their common ICD-9 diagnosis in ICD-10 language.

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Manage My Practice: What do you hear are the biggest challenges faced by practices in making the transition to I-10?

SpringSoft: We hear that immediacy and time are the biggest challenges. Immediacy – it is always easier to learn new methods when you can consistently work in the new method. A baseline understanding helps provide context and what the changes are. We will all learn when everyone starts coding in ICD-10. Time – the change to ICD-10 is not trivial. It impacts the office’s income. Everyone will need to spend a little more time – coding in ICD-10, and time in improving their coding as payers respond to codes submitted. A practice can reduce frustration if they understand and prepare for their learning curve. Like all new methods, it takes practice to perfect.

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Manage My Practice: For many practices, their ability to utilize ICD-10 will come down to the support the EHR or Practice Management vendor has built into the software, yet many practices have not even seen how their software will work with ICD-10. What do recommend for practices whose software has not yet been updated to I-10, or whose software makes no useful correlation between I-9 and I-10?

SpringSoft: We agree with many consultants and trainers. Transition your top ICD-9 codes to specific ICD-10 codes. Be cautious of depending on published crosswalks. ICD-9s which describe ‘unspecified’ elements often are crosswalked to ‘unspecified’ ICD-10s. Experts in the industry are cautioning that ‘unspecified’ ICD-10s may not be paid. Ask your EMR vendor, will you handle all of the ICD-10 coding guidelines, such as Code First, Code Also, Use Additional Codes? Will you map to ‘unspecified’ ICD-10 codes or warn me of ‘unspecified’ ICD-10 codes? How will you help me find more specific codes? You can use Swiftaudit Search to build your Favorites Lists. We will provide you the ICD-10 coding guidelines, and provide a communication platform for your expert coders to provide you with coding tips and alerts.

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Manage My Practice: What are some of the features in Swiftaudit Search that your product has that others you’ve seen do not?

SpringSoft: We feel that our ease of use and screen design makes us stand out from the crowd. The ICD-10 code set is overwhelming. We’ve worked very hard to provide the information you need at a glance.

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Manage My Practice: Swiftaudit Pro (as opposed to Swiftaudit Search) is more for the coding and billing side of the practice. How do you see coders and billers using this product in their practices?

SpringSoft: Our background is in coding and compliance. Managers and auditors can use Swiftaudit Pro to improve their coding accuracy and educate their providers. We built Swiftaudit Pro to be a communication platform to aid discovery and process improvement between a practice’s providers and expert coders.

Readers who would like more information or would like to try Swiftaudit Search for free for 30-days can click here.

NOTE: We’ve heard of so many practices that have not started preparations for ICD-10 that that we made the 20-minute webinar “ICD-10 CM: Getting Started Today.” The video addresses strategies for the first step – crosswalking your most used ICD-9 codes into ICD-10.

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Posted in: Collections, Billing & Coding, Day-to-Day Operations, Electronic Medical Records, Headlines, ICD-10, Medicare & Reimbursement

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The CMS ICD-10 Announcement: What It Means to Your Practice

The Lion and the Lamb - CMS and the AMA Collaborate on ICD-10 Concessions

First, the game-changing announcement below means that a sigh of relief is in order. Some of the anxiety surrounding potential financial disaster should be abated. CMS announced:

“Medicare review contractors [MACs and RACs] will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.” (see FAQ2 below)

Second, we think it means that the sword rattling coming from the AMA and other individuals should subside. The fact that the CMS changes are based on recommendations from the AMA, which has been adamantly opposed to the ICD-10 mandate for years, is no less unexpected than the lion laying down with the lamb.

Regardless of the changes, the AMA’s previous assertion that ICD-10 “will create significant burdens on the practice of medicine with no direct benefit to individual patients’ care” still stands. The transition is inevitable, in my mind, but the changes will lessen the burden on physicians.

In the announcement from CMS, the clarification was made that

“In accordance with the coming transition, the Medicare claims processing systems will not have the capability to accept ICD-9 codes for dates of services after September 30, 2015, nor will they be able to accept claims for both ICD-9 and ICD-10 codes.”

Third, CMS will name a CMS ICD-10 Ombudsman to triage and answer questions about the submission of claims. The ICD-10 Ombudsman will be located at CMS’s ICD-10 Coordination Center.

Also, mark your calendars! CMS will have a provider call on August 27th to discuss these changes.

See the answers below provided by CMS in their new FAQs published this week.

Q1. What if I run into a problem with the transition to ICD-10 on or after October 1st 2015?

A1. CMS understands that moving to ICD-10 is bringing significant changes to the provider community. CMS will set up a communication and collaboration center for monitoring the implementation of ICD-10. This center will quickly identify and initiate resolution of issues that arise as a result of the transition to ICD-10. As part of the center, CMS will have an ICD-10 Ombudsman to help receive and triage physician and provider issues. The Ombudsman will work closely with representatives in CMS’s regional offices to address physicians’ concerns. As we get closer to the October 1, 2015, compliance date, CMS will issue guidance about how to submit issues to the Ombudsman.

Q2. What happens if I use the wrong ICD-10 code, will my claim be denied?

A1. While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family. However, a valid ICD-10 code will be required on all claims starting on October 1, 2015. It is possible a claim could be chosen for review for reasons other than the specificity of the ICD-10 code and the claim would continue to be reviewed for these reasons. This policy will be adopted by the Medicare Administrative Contractors, the Recovery Audit Contractors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor.

Q3. What happens if I use the wrong ICD-10 code for quality reporting? Will Medicare deny an informal review request?

A3. For all quality reporting completed for program year 2015 Medicare clinical quality data review contractors will not subject physicians or other Eligible Professionals (EP) to the Physician Quality Reporting System (PQRS), Value Based Modifier (VBM), or Meaningful Use 2 (MU) penalty during primary source verification or auditing related to the additional specificity of the ICD-10 diagnosis code, as long as the physician/EP used a code from the correct family of codes. Furthermore, an EP will not be subjected to a penalty if CMS experiences difficulty calculating the quality scores for PQRS, VBM, or MU due to the transition to ICD-10 codes. CMS will not deny any informal review request based on 2015 quality measures if it is found that the EP submitted the requisite number/type of measures and appropriate domains on the specified number/percentage of patients, and the EP’s only error(s) is/are related to the specificity of the ICD-10 diagnosis code (as long as the physician/EP used a code from the correct family of codes). CMS will continue to monitor the implementation and adjust the timeframe if needed.

Q4. What is advanced payment and how can I access this if needed?

A4. When the Part B Medicare Contractors are unable to process claims within established time limits because of administrative problems, such as contractor system malfunction or implementation problems, an advance payment may be available. An advance payment is a conditional partial payment, which requires repayment, and may be issued when the conditions described in CMS regulations at 42 CFR Section 421.214 are met. To apply for an advance payment, the Medicare physician/supplier is required to submit the request to their appropriate Medicare Administrative Contractor (MAC). Should there be Medicare systems issues that interfere with claims processing, CMS and the MACs will post information on how to access advance payments. CMS does not have the authority to make advance payments in the case where a physician is unable to submit a valid claim for services rendered.

NOTE: Watch for upcoming posts on ICD-10 websites and apps that I am rating for their usefulness. We will also be producing free webinars on translating the diagnoses on your superbills, picklists and cheat sheets for ICD-10 – stay tuned!

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ICD-10: Practices Should Focus on Just 3 Things

ICD1-10: Medical Practices Should Focus on Three Things

There is a lot of advice out there on making the transition to ICD-10.

Your medical practice may already have taken some of this advice and you are well on the way to readiness for I-10. But if you’ve not done anything yet for the transition, this article is for you. I’ve distilled all the blah-blah-blah down into three easy steps that any practice can follow to embrace the change.

1. Do You Need More Software Support?

There is no question that most everything hinges on your EMR and billing system’s management of ICD-10. Your vendor may say the system is I-10 ready, but what does that really mean?

Ask your vendor these questions:

  1. Are ICD-10 codes available in the system now? If not now, when?
  2. Can the providers and staff rehearse using I-10 inside the system by dual coding and assigning both an ICD-9 and an ICD-10 to services without having the I-10 drop to the claim?
  3. What support, if any, does the system give for choosing the right ICD-10? Is there any type of translator or crosswalk between I-9 and I-10?
  4. After October 1, 2015, will the software have the ability to use an I-10 or crosswalk from 10 to 9 if the payer does not accept 10? It should! Physicians and coders/billers should not have to look at the patient’s payer of record to decided which one to use, nor should they require you to change the I-10 to I-9 on the back end. It is very doable for software to crosswalk from 10 to 9 for you.

If the software supports getting to the most specific ICD-10 possible, not just picking the first one that vaguely matches, choosing the I-10 should be straightforward.  If your software does nothing more than save the I-10 codes you choose to a favorites or a pick list, then you will need a standalone piece of software called an “encoder.” Hospitals and mega practices have been using encoders for years to help navigate the maze of Medicare local and national rules.

Practices without sufficient support from their EMR/Billing software will need an encoder that can not only suggest possibilities for ICD-10 codes, but can also assist in finding the right code from a series of words algorithmically ordered. (If you want to know which encoder is my particular favorite, send me an email at marypat@managemypractice.com.) Encoders also usually have additional benefits that your billing software or claims scrubber may not have such as CCI edits, modifier rules, global period and wRVU information.

Example of the drilling down to the correct I-10 diagnosis assisted by an encoder:

Fracture:

  • Cause?
  • Which bone? Which part of the bone? Laterality?
  • Type of fracture? Open, closed, displaced, non-displaced?
  • Encounter? Initial, Subsequent, Sequela?
  • External cause?
  • Associates diagnoses, conditions?

2. Could Documentation Be Brushed Up?

In hospitals, entire teams of people (Clinical Documentation Improvement staff, usually nurses) are dedicated to making sure that the documentation can support the specificity of the I-10 code chosen. This is especially important for the hospital side of reimbursement.

In the hospitals there are often silos between the service providers and the coding review and billing staff. In practices, we have the good fortune to be able to reflect on the documentation once the I-10 code is chosen, and clarify the documentation on the spot if needed.

Some easy ways to make sure your documentation is as complete as possible to support the I-10 code are:

  • Think of MEAT when you document. Every condition in your documentation should be described as Monitored, Evaluated, Assessed and/or Treated. If the patient has an existing diagnosis that you did not address during the visit, don’t put it in the documentation or on the claim.
  • Use “due to” or “manifested by” for each problem that you describe, if you know that information.
  • Change/improve your EMR templates (or paper progress note format) to accommodate the points above.

3. Are You Ready for Cash Flow Interruption?

You’ve heard this for years and it remains a legitimate concern. If there is any problem with claims processing OR if you are not using ICD-10 properly causing denials, there is a good chance your money from insurance companies will slow down or even dry up for awhile. I suspect that insurance companies may use ICD-10 as a handy excuse to delay payment regardless of the plethora of other excuses they have to choose from.

Predictions on the cost of ICD-10 fluctuate wildly, but here are the places you are most likely to feel the financial pain:

  • If your EMR/Billing system wants you to pay for an upgrade to your software to compensate them for the money they’ve spent upgrading their software. Since the delay, I’ve heard of fewer companies requiring a special payment for the upgrade.
  • Reduction of productivity based on time spent to choose an I-10 code:
    • Any manual form in your practice that uses ICD-9 will need an ICD-10. How will you find those codes?
    • Physicians who choose codes through their EHR will need software support to find those codes. Because there are so many more codes due to the specificity of each code, it will take a while to get the hang of it if you are not using an encoder.
  • Inability of your clearinghouse to send claims. Unless you are directly submitting claims to any payers, your clearinghouse has probably tested (end-to-end, please) with payers. Ask your clearinghouse who they’ve tested end-to-end with and what the results were. If things really bog down with CMS, they may grant advance Medicare payments to physicians that are not receiving payments due to the ICD-10 transition.
  • Delay in payment from any payer due to ICD-10 general chaos.

Keep in mind that a lot of the hoopla over ICD-10 has been on the hospital side. Physician practices are very lucky in that we use CPTs for reimbursement (at this point), not diagnoses. This is a huge change for the hospital/facility side, but much less of a transition for medical practices. We are hoping that physician practices will have less impact to their bottom line, but you should be ready with a line of credit or some extra funds in the bank for this possible rainy day. Starting today, practices that make distributions to owners quarterly may want to scale this back until the smoke clears.

Resources to Help You:

AHIMA (American Health Information Management Association (AHIMA)  has an a nice set of tools relating to the adoption of ICD-10 here. Not all tools are available for non-members.

CMS Road to 10: The Small Physician Practice’s Route to ICD-10 compiles resources from the AAPC (American Association of Professional Coders) AHIMA, the AMA (requires AMA login) and CMS/PAHCOM (Professional Association of Healthcare Office Managers) produced resources.

The AAPC has lots of high-quality offerings here, most for members or for purchase by nonmembers. Although it was written for the original 2014 transition, here’s a good article to review for the creation of an ICD-10 superbill, or just to review your top I-9s and translate them to I-10s.

Your software vendor, claims clearinghouse and specialty society should also have ICD-10 tools.

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Posted in: Collections, Billing & Coding, Compliance, Day-to-Day Operations, Finance, Headlines, ICD-10

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New 1500 Claim Form Approved to Accommodate ICD-9 or ICD-10 Diagnosis Codes

NUCC Announces Approval of New 2/12 1500 Form for ICD-9 and ICD-10 Accommodation

On June 17, 2013, the National Uniform Claim Committee (NUCC ) announced the approval of Version 02/12 1500 Health Insurance Claim Form (1500 Claim Form) that accommodates reporting needs for ICD-10. The Office of Management and Budget (OMB) has approved the 1500 Claim Form under OMB Number 0938-1197.

During its work, the NUCC was made aware by the health care industry of two priorities that were included in the revisionsto the 1500 Claim Form. The first was the addition of an indicator in Item Number 21 to identify the version of the diagnosis code set being report, i.e., ICD-9 or ICD-10.

The need to identify which version of the code set is being reported will be important during the implementation period of ICD-10.

The second priority was to expand the number of diagnosis codes that can be reported in Item Number 21, which was increased from 4 to 12. Additional revisions will improve the accuracy of the data reported, such as being able to identify the role of the provider reported in Item Number 17 and the specific dates reported in Item Number 14.

Frequently Asked Questions (as of 6/17/13)

1. Why was the 1500 Claim Form changed?

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Posted in: Collections, Billing & Coding, ICD-10, Medicare & Reimbursement

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