ICD-10: Frequently Asked Questions
Looking for more information about the mandated transition to ICD-10? Wondering how this may
impact the way health care providers do business with Mayo Clinic Health Solutions? Please review this
list of frequently asked questions.
Employer FAQs
Below are answers to employer-specific ICD-10 questions. For more general information about ICD10, please review the other FAQs in this document.
How will members know if their claim was denied because the wrong ICD code was used?
If a claim is denied due to the use of the wrong ICD code, the member will see a service code and a
note on their Explanation of Benefits (EOB) explaining why the claim was denied. The provider will
see a similar message on their Remittance Advice.
What should the member do to make sure their claim is refiled with the correct code?
The note on the member’s EOB (mentioned above) instructs the member to refer to the claim filing
provisions of their plan documents. The member’s plan documents provide guidance on how to
resubmit a claim. Since most claims are filed by the provider on the member’s behalf, the member
may wish to contact their billing provider about this issue. As mentioned above, the provider will
also be notified of the ICD code issue on their Remittance Advice.
What is ICD-10?
ICD-10 (International Classification of Diseases, tenth revision) is a diagnostic coding system
implemented by the World Health Organization (WHO) to replace ICD-9, which was developed by
WHO in the 1970s. The ICD code set is used to classify diseases and causes of illness recorded on claims
and health records.
In the United States, when we refer to ICD-10 we are referring to the U.S. clinical modification of ICD10, ICD-10-CM. The Department of Health and Human Services (HHS) issued a final rule in 2009
requiring covered entities that conduct electronic HIPAA standard transactions to transition from ICD9-CM (our current code set) to ICD-10-CM code sets. ICD-10-CM is scheduled to replace ICD-9-CM on
October 1, 2015.
ICD-10-PCS is a procedural coding system developed for reporting hospital procedural claims. ICD-10-PCS
has no relationship with WHO.“ICD-10” is used as part of its name because the Centers for Medicare &
Medicaid Services (CMS) wanted to link it to ICD-10-CM. After the implementation of ICD-10, hospitals will
report the procedures patients undergo using ICD-10-PCS; however, physicians will continue to report their
®
services using the Current Procedural Terminology (CPT ) code set.
How does ICD-10 compare to ICD-9?
Similarities: ICD-10-CM is similar to ICD-9-CM in many ways. The code sets share similar guidelines,
conventions and rules. In addition, the organization of the codes are very similar.
Differences: ICD-10-CM introduces many improvements to coding. For example, in fracture care,
the code can now differentiate between the initial encounter and many different types of follow-up
encounters. The most important differences between ICD-10-CM and ICD-9-CM have to do with
differences that impact information technology and software:
• ICD-10-CM now allows for more characters (three to seven) and requires a decimal point.
• Codesarealphanumeric,allowinglateralityandprovidingagreaterdegreeofspecificity.
ICD-10-PCS have been completely revised. The revision will not affect CPT coding; however, physicians
should be aware that documentation requirements will be significantly different, impacting inpatient
medical record documentation.
• Codeshavesevencharactersandnodecimalpoints.
• Codesarealphanumeric.
• Codesareconstructedthroughtheassignmentofcharacters,eachonerepresentinganaspectofthe
inpatient procedure.
When is the ICD-10 implementation date?
The Department of Health and Human Services (HHS) has mandated that ICD-10-CM and
ICD-10-PCS be implemented effective October 1, 2015. Claims for all health care services and hospital
inpatient procedures performed on or after October 1, 2015, must use ICD-10 diagnosis and inpatient
procedure codes.
What is Mayo Clinic Health Solutions doing to prepare for the ICD-10 conversion?
Mayo Clinic Health Solutions has a dedicated ICD-10 team working on execution of the conversion
project. Planning has been completed; systems and processes are being updated to accommodate ICD10 functionality. Testing of these new systems and processes will begin in July 2013 and will continue
through the third quarter of 2015.
How will Mayo Clinic Health Solutions convert ICD-9 data to the ICD-10 format?
Mayo Clinic Health Solutions is planning to use a method called “native redefinition” to convert ICD-9
data to the ICD-10 format. Native redefinition is the process of directly researching appropriate codes that
apply to policies, rules, processes, or categories based on the standard definitions in code documentation.
Other conversion processes using crosswalks and general equivalence mappings (GEMs) were also
considered; however, native redefinition was chosen as it is considered more accurate and reliable.
Crosswalks and GEMs may be used in reporting or underwriting.
What is Mayo Clinic Health Solutions’ ICD-10 implementation timeline?
Mayo Clinic Health Solutions will be compliant by October 1, 2015, the mandated implementation date.
Key milestone dates include:
• IntegratedInternalTesting:May2015-August2015
• ExternalTesting:June2015-August2015
Will Mayo Clinic Health Solutions accept ICD-9 codes after the implementation of ICD-10 for
dates of service prior to the ICD-10 implementation date?
Yes, Mayo Clinic Health Solutions will retain the ability to process both ICD-9 and ICD-10 codes after
implementation; however, ICD-9 codes will only be accepted on claims with dates of service prior to
October 1, 2015. The ICD-10 code set must be used on all outpatient/professional claims with dates
of service, and inpatient claims with a date of discharge, on or after October 1, 2015. This requirement
applies to both electronic and paper claims.
Can claims be submitted using a combination of ICD-9 and ICD-10 codes?
No. The Centers for Medicare & Medicaid Services (CMS) will allow only one code set per claim (i.e., all
ICD-9 codes or all ICD-10 codes). The use of two code sets on one claim renders the claim unprocessable
and will result in a denial.
What should providers do to prepare for the transition to ICD-10?
An ICD-10 transition plan should take into account specific practice or organization needs, vendor
readiness, and staff knowledge and training. Providers can begin to prepare by taking the following steps.
It is critical not to delay planning and preparation.
• Contactyourbillingservice,clearinghouse,orpracticemanagementsoftwarevendorandaskthem
about their readiness plans. (Providers who handle billing and software development internally
should plan for medical records/coding, clinical, information technology and finance staff to
coordinate ICD-10 transition efforts.)
• IdentifyICD-9(andpresumablyICD-10)touchpointsinyoursystemsandbusinessprocesses.
• Identifyneedsandresources,suchastraining,printing,budget,etc.
• Developaprojecttimelineandshareitwithallstakeholders.
Will Mayo Clinic Health Solutions conduct testing with providers using ICD-10 codes?
Yes, Mayo Clinic Health Solutions will conduct thorough testing prior to October 1, 2015. We are currently
working with trading partners to establish testing timelines and expectations that align with our
implementation timeline.
How will Mayo Clinic Health Solutions communicate with providers about the
ICD-10 transition?
Mayo Clinic Health Solutionswill communicate with all contracted and non-contracted providers about
the ICD-10 transition through the Online Services for Providers tab at www.MayoClinicHealthSolutions.
com. In addition, contracted providers will receive quarterly updates through the eUpdate for Providers
newsletter.
Where can providers find additional ICD-10 information and guidance?
ICD-10 resources and training materials are available through CMS, professional associations and
societies, and software/system vendors:
• AmericanHealthInformationManagementAssociation(AHIMA)ICD-10CM/PCS
• CentersforMedicareandMedicaidServices(CMS)ICD-10
• HealthcareInformationandManagementSystemsSociety(HIMSS)ICD-10Playbook
• ICD10WatchHealthcareITNewsandHealthcareFinanceNews
• WorldHealthOrganizationBackgroundinformationandhistoryofICD
In addition, look for specialty-specific ICD-10 training offered by societies and other professional
organizations. ICD-10 coding training will be integrated into the continuing education that certified
coders must take to maintain their credentials.
www.MayoClinicHealthSolutions.com
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