Regence BlueShield of Idaho
ICD-10 Frequently Asked Questions
Contents
Readiness/Remediation plans: ................................................................................................................. 2
Policy: ........................................................................................................................................................ 2
Pre-authorization: ..................................................................................................................................... 5
Testing:...................................................................................................................................................... 7
Cut over:.................................................................................................................................................... 7
Communication:........................................................................................................................................ 8
Page 1 of 8
Revised September 2015
Readiness/Remediation plans:
1. What are Regence’s plans for ICD-10 acceptance?
•
We will remediate all our systems to be able to handle ICD-10 codes.
•
We will reject claims with non-compliant ICD codes on or after the ICD-10 implementation date
(based on date of service).
2. Will Regence be ready for migration to ICD-10 on the ICD-10 implementation date?
Yes.
3. What “claims scrubbing” edit changes will be made to Regence software to process ICD-10
claims? When will Regence be able to provide an explanation of how these new edits will
impact operations?
Regence is working on remediating our claims processing for ICD-10 codes with the goal of changing
claims processing as little as possible. We are staying consistent with our current ICD-9 edits, in that
we require valid codes on claims. We will edit based on dates of service in accordance to
CMS guidelines.
4. Did Regence complete analysis on potential Diagnosis Related Group (DRG) shifts?
. We have been analyzing the DRG shifts internally and working with providers directly to understand
DRG shift implications.
5. What DRG version will you be supporting for ICD-10 go-live?
We will be supporting MS-DRG version 33 for ICD-10.
Policy:
6. Will providers and facilities need to re-negotiate electronic data interchange (EDI) agreements
based on the ICD-10 conversion?
We do not anticipate any changes to the existing EDI agreements. HIPAA 5010 was implemented to
support ICD 10 changes. We therefore do not expect any direct EDI impacts.
7. Will Regence require valid ICD codes for all contract types (e.g., hospital, professional
provider, and/or ancillary services)?
Yes, all provider agreements require use of valid codes.
8. Will providers and facilities need to re-negotiate provider agreements based on the
conversion to the new ICD-10 codes?
As our provider contract language addresses reconciliation if payments are found to be higher or
lower due to ICD-10, we do not anticipate any renegotiations based on ICD-10 codes.
9. What impact will ICD-10 have on Regence fee schedules, medical review, auditing
and coverage?
Our intent is to be as financially and operationally neutral as possible.
10. What impact will ICD-10 have on medical management?
Our intent is to limit changes to our medical management thus minimizing any impact to providers
and facilities.
11. When does your health plan intend to update and release your medical necessity
lists/guidelines to include ICD-10 and related codes/descriptions?
Our medical policies which outline medical necessity do not contain ICD codes so will not need to be
updated for ICD-10 implementation. There are a few medical policies that do have condition
descriptions but these should not require updating prior to ICD-10 implementation.
Page 2 of 8
Revised September 2015
12. Once you convert to ICD-10, will you still accept ICD-9? If not, what is the plan for payers not
required to convert (auto/work comp)?
We will accept ICD-9 codes on claims with dates of service prior the ICD-10 implementation date and
require ICD-10 codes for dates of service on or after the ICD-10 implementation date.
13. Will you accept a Letter of Agreement (LOA) for periodic interim payments (PIPs) thus
ensuring payment to the hospital if claims processing exceed contract limits for clean claims
and payment terms (as defined by contract and/or state regulation)?
This can be discussed at contract negotiations.
14. What methodology will you use to move codes from ICD-10 to ICD-9 in order to obtain the
appropriate DRG and DRG based payment?
Regence will not translate codes on claims for adjudication or provider payment purposes. We will
process the native code that we receive from the provider.
15. Will you support the paper claims submission?
All providers in Idaho, Oregon, Utah and Washington must submit claims electronically. We would
only accept paper claims submissions for providers outside of our four State regions of Idaho,
Oregon, Utah and Washington.
16. Will you require ICD-10 PCS codes on outpatient claims?
No.
17. Will you accept unspecified codes?
Yes. However, all ICD coding must be coded to the highest level of specificity that is known at the
time of each health care encounter.
Please note: for neonate claims there are neonate specific diagnosis codes that might be more
appropriate to use than adult or unspecified diagnosis codes.
18. Will you allow ICD-9 and ICD-10 claims in the same claim submission file?
Yes
19. Will you allow ICD-9 and ICD-10 codes to be submitted on the same claim?
No
20. With the increased level of specificity in the ICD-10 code set, will DSM codes still be accepted
or will ICD-10 codes be required for submission?
Regence will require ICD-10 codes for all mental health claims with dates of service on or after the
ICD-10 implementation date for adjudication of claims. We can continue to also accept DSM-5 as
supplemental coding.
21. ICD10 provides two new codes for reporting findings during an exam (i.e., Z00.00 - normal
finding and Z00.01 - abnormal finding). Given that Regence would receive a claim coded as
follows (e.g., Preventive E&M code with an abnormal diagnosis code (e.g. Z00.01) and an
additional diagnosis code is present that identifies the abnormal finding or medical concern)
would Regence process it as medical, preventive or pend/deny for additional information?
We have mapped both of those codes to preventive categories. Even if abnormal findings come out
of a preventive exam, the member still went in for a preventive exam and we will treat as such.
22. Have there been changes to Present on Admission (POA) indicators for ICD-10?
Yes, POA requirements differ under ICD-9 than in ICD-10. If the appropriate ICD-10 POA indicator is
not on the claim for dates of service on or after October 1, the claim will be denied and the Facility will
need to resubmit with appropriate POA indicator.
Page 3 of 8
Revised September 2015
23. Health plans currently have a customary turnaround time for notifying providers, via a
remittance advice, about the adjudication of initially submitted claims. This turnaround time
acts as a trigger date for providers to follow-up with the health plan if the remittance advice is
not received. With the go-live implementation of ICD-10, if a remittance advice for an initially
submitted claim is later than this customary turnaround time, what is your recommended
escalation path and timeframe for providers to follow? For example, if your standard
turnaround time for a remittance advice is 14 days from receipt, would you like us to escalate
at day 15, day 21, or other?
Provider’s first point of verification should be their denial reports from their vendors to assure that
their claims are going to the Health Plan correctly. The providers are aware of the regular remittance
advice date and if the remittance advice is late for any reason the Health Plan posts that information
on the provider website. Regence would ask that a provider wait 45 days to allow a claim to be
processed before contacting us or the provider can view claims on Availity.
24. What if a claim is rejected by Availity for a non-compliant ICD code?
The same process that occurs today will continue as it relates to submission of invalid codes. Availity
will reject the code and will not transmit it to Regence for claims processing. Provider and facilities
first point of verification for invalid code submission should be their denial reports from their vendor to
assure that valid codes are being submitted on your claims.
25. What if the ICD code is valid, however the claims processing outcome was not what the
provider or facility expected?
If ICD codes on the claim are valid (based on date of service), they will be transmitted from Availity to
Regence for claims processing. However, if other problems related to how you have mapped the ICD10 code has caused the claims processing outcome to not be what you expected, please review with
your Information Technology department and contact your assigned provider relations representative
to report the issue and we will help to take appropriate steps for resolution. We will have in place an
internal ICD-10 escalation process in place to quickly resolve issues.
26. Will Regence have any new provider remittance advice explanation codes that pertain
to ICD-10?
There have been no new provider remittance advice explanation codes developed specific to ICD-10.
27. Are there any changes to your policy based on the recent announcement by CMS and AMA in this
article http://www.healthcareitnews.com/news/icd-10-cms-wont-deny-claims-first-year?
There is no change to our policy, we follow CMS guidelines and accept valid ICD-10 codes.
The announcement states that CMS will relax claims auditing requirements. However, valid ICD-10
coding will still be required for claims submission. Please see the answer to Question #2 in this CMS
guidance publication that accompanied the CMS/AMA announcement:
http://cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10-guidance.pdf. Here is the question and
answer for your reference:
Q. What happens if I use the wrong ICD-10 code, will my claim be denied?
A. 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.
Page 4 of 8
Revised September 2015
Please note that this announcement applies only to Medicare Part B – primarily Professional claims.
The key piece of information to note in this article is highlighted below, the providers are still required
to send us valid ICD-10 claims on or after October 1, 2015:
1. Claims denials. "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," CMS officials wrote in a guidance document.
28. What is your policy on Workers Compensation claims?
We will only accept ICD-10 codes for dates of service on or after October 1, 2015. This applies to all
claims including workers compensation claims.
Pre-authorization:
29. What changes do you anticipate in the authorization process?
Our intent is to have the authorization process work as closely as possible to the current process after
the ICD-10 introduction.
30. When will changes to the authorization process be published and available?
We are not anticipating any further changes to our authorization process due to ICD-10.
31. Will authorization changes be negotiated during the contract review process?
We do not anticipate any authorization changes because of ICD-10.
32. Will there be changes in the code specificity requirements on authorization?
Our current requirement is that providers’ code to the highest level of specificity that can be
determined at the time of each health care encounter. This requirement remains the same
under ICD-10.
33. At what point will you require ICD-10 codes for authorization?
We will require ICD-10 codes on or after the ICD-10 implementation date.
34. Will ICD-10 authorization requirements be based on date of service or the date authorization
is requested?
They will be based on the date the authorization is requested.
35. How will you handle an authorization that covers multiple dates of service, some of which are
prior to the ICD-10 implementation date and some after? Will two different pre-authorization
numbers be required?
This is not an issue for Regence as we do not use ICD codes to match the pre-authorization with the
subsequent claim. It will not be necessary to have two different pre-authorizations.
36. If an inpatient admission overlaps a compliance date:
a. Will reauthorization be required in ICD-10 or will original authorization in ICD-9
be sufficient?
The original authorization in ICD-9 will be sufficient.
b. Will both ICD-9 and ICD-10 codes be required for authorization on admissions that are
within a certain time of the compliance date?
No. ICD-9s will be required on or before the implementation date. ICD-10 will be required on or
after the ICD-10 implementation date.
Page 5 of 8
Revised September 2015
37. Will there be a grace period when ICD9 codes will be accepted for authorization after the
compliance date?
No.
38. If you have online forms, when will these be updated and available for review?
Minimal changes to the forms were made in 2014 to accommodate both ICD-9 and ICD-10 codes. No
further changes are anticipated.
39. Will your policy AND/OR your guidelines for referrals (and any requirement for the preauthorization of those referrals) change with the implementation of ICD-10?
Policies and guidelines will not be changing.
40. Is any part of the pre-authorization process outsourced? If yes, should providers contact that
organization about their readiness or just work through you?
Regence does outsource the pre-authorization process for some services to vendors, (e.g., AIM
Specialty HealthSM and eviCore healthcare [formerly CareCore National]) performed by our vendors
are based on type of service and CPT/HCPCS coding, not on ICD coding. Providers therefore should
not need to contact our vendors regarding their readiness.
41. When do you intend to update and release your pre-authorization lists to include ICD-10
codes/descriptions?
ICD codes and descriptions are not specified in our pre-authorization lists and we are not planning to
add them.
42. When do you intend to update and release your medical necessity lists/guidelines to include
ICD-10 and related codes/descriptions?
Our medical policies which outline medical necessity do not contain ICD coding so will not need to be
updated for ICD-10 implementation
43. When will you update the online tool to be compliant with ICD10? When will you update the
fax form?
Our forms have all been revised to accommodate either ICD-9 or ICD-10.
44. What is the earliest date (prior to the ICD-10 implementation date) that your health plan will
accept pre-authorization requests with ICD-10 codes/descriptions?
We accept pre-authorizations 60 days prior to service. Our Pre-authorization Request Form allows
entry of an ICD code or description; however our preference is the ICD code. Our pre-authorization
request form can accommodate ICD-9 or ICD-10 codes.
45. How will you handle the situation when there is a conflict between the ICD code/description
version that was authorized and the ICD code/description version that was used for the actual
date of service?
This is not an issue for Regence as we do not use ICD codes to match the pre-authorization with the
subsequent claim.
Page 6 of 8
Revised September 2015
Testing:
Disclaimer: “As part of the testing with providers, we may discover issues that require rework internally.
We will share testing results with our provider partner; however, though our test system is similar to our
production system, we cannot guarantee that our production system will perform exactly the same as
our test environment after implementation.”
Please note: It is not feasible to test with all providers due to resource and budget constraints.
46. What is your ICD-10 testing and implementation plan (key milestones) and schedule
for ICD-10?
We have completed all provider partner testing.
47. For providers you will not be testing with, how will you communicate your general ICD-10
testing feedback?
We will communicate via our provider website and through The ConnectionSM, our provider
newsletter, if we have updates that can be communicated generally.
48. Will you test paper claims?
We do not plan to test paper claims submissions but we have confirmed manual claims entry
and processing.
49. Will you test with ICD-9 claims or ICD-10 claims or both?
We tested with only ICD-10 claims.
50. Is there a date before the ICD-10 implementation date when all your claim edits (any edits not
just ICD10-related) will be submitted to the clearing houses and frozen until after the
implementation date?
The majority of our edits are currently in place in production for ICD-10. Our vendor does supply
monthly software updates, however; we would deal with any changes to ICD-10 codes as soon
as possible.
Cut over:
51. How will Regence account for processing both ICD-9 and ICD-10 codes based upon dates of
service before and/or after the ICD-10 implementation date?
We will accept and process valid ICD-9 for date of service before the ICD-10 implementation date
and valid ICD-10 codes for date of service on or after the ICD-10 implementation date.
52. If an inpatient facility claim spans the ICD-10 cutover date, should ICD-9 or ICD-10 codes be
used on those claims?
For inpatient facility claims, the date of discharge determines the ICD code set to be used in most
cases. A single claim with ICD-10 codes can be submitted for an inpatient stay that spans the
cutover. In some special circumstances (as detailed in the MLN Matters MM7492 article), CMS
requires providers to split a claim into two parts for before and after the cutover. We will follow CMS
guidelines for how to process claims that span the ICD-10 implementation date. No claim may contain
a mixture of ICD-9 and ICD-10 codes.
53. How will you ensure no disruption to the claims adjudication process throughout the
conversion process?
Regence plans to do extensive testing, training of staff and will adjust staffing levels where
necessary. Our goal is to limit any impacts and business disruption.
Page 7 of 8
Revised September 2015
Communication:
54. How will Regence communicate progress and schedule to keep customers informed?
Regence will maintain updated information in the Claims & payment section of our website under
ICD-10 at regence.com. In addition, we will provide updates as necessary in our provider newsletter,
The Connection located in the Library section of our website.
55. Where can I find additional information related to ICD-10?
Additional information is available on the following websites:
• Idaho ICD-10 Collaborative at www.idahoicd10.org/
• American Medical Association at www.ama-assn.org/
• Centers for Medicare & Medicaid Services at www.cms.gov/ICD10/
• Availity at www.availity.com/resources/icd-10-revenue-cycle-management/
• OneHealthPort ICD-10 Information Central at www.onehealthport.com/content/icd-10information-central
56. Who are the people in your company that are the best ICD-10 contacts?
For any claims or billing related issues, please follow your normal processes.
Page 8 of 8
Revised September 2015