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ICD-10 frequently asked questions

When will Keystone First be ICD-10 compliant?

Keystone First's implementation plan calls for us to be ICD-10 compliant by October 1, 2015.

Is Keystone First experiencing any claims issues with ICD-10 implementation?

No claims issues have been identified at this time as part of the ICD-10 implementation. Any issue identified as part of our ICD-10 project has been remediated. Our ICD-10 Governance Committee has successfully tested more than 300,000 ICD-10 test claims in our claims systems.

Will Keystone First conduct any testing directly with providers?

Keystone First has scheduled our testing window to start on August 1, 2015, and continue through August 30, 2105. Providers were able to sign up for testing by July 1, 2015. Our approach is to allow providers to submit test ICD-10 claims through their respective clearinghouses to Keystone First for claims processing and adjudication. Participating test providers will receive an 835 remittance advice after claim adjudication. This provider testing is not intended to provide financial neutrality information. We will continue to keep you updated on the testing results.

Will Keystone First allow a time period before or after the ICD-10 implementation where providers are advised or educated of denials due to specificity edits?

Keystone First has not implemented new edits as part of the ICD-10 implementation. The existing ICD-9 edits, including those for specificity, will remain in place and have been remediated for ICD-10. Providers will continue to receive any denial reason codes as received in the current ICD-9 processes.

Will Keystone First start accepting ICD-10 codes on claims before October 1, 2015?

No, we will not be accepting ICD-10 claims before October 1, 2015. Even though we are working on becoming ICD-10 compliant well before the current government-mandated date, the U.S. Department of Health and Human Services, in accordance with the Health Insurance Portability and Accountability Act (HIPAA), does not allow us to accept ICD-10 codes before the government-mandated date.

What changes has Keystone First made to the claims processing system to prepare for ICD-10 implementation? Are the changes complete?

Keystone First has a formal ICD-10 remediation strategy in progress for our claims processing systems. The remediation and strategy include modification of field lengths to accept the new ICD-10 code lengths (7 characters for ICD-10, 5 characters for ICD-9) and ICD code qualifier fields to allow ICD-10 values; database table remediation to accept code lengths; updated code definitions within Facets; and remediation of data warehouse storage methods. The remediation is completed and testing is scheduled to finish in June 2015.

How will prior authorizations be impacted by the ICD-10 implementation?

Prior authorizations should be requested with an ICD-9 or ICD-10 code, depending on the discharge date or date of service, if known, at the time of the prior authorization request. If the date of service or discharge date corresponding to the prior authorization is before October 1, 2015, an ICD-9 code should be used on the prior authorization. If the admission date corresponding to the authorization is before the compliance deadline but the discharge date is unknown, an ICD-9 code will suffice and will not impact the payment or processing of a provider's claim even if the discharge is after the ICD-10 compliance deadline.

For any prior authorizations requested where the date of service or discharge date is known to be on or after October 1, 2015, the authorizations should be requested with an ICD-10 code. The below table provides recommendations of which code types to use in which scenarios for both inpatient and outpatient services. Please note this grid supports best practice relative to authorizations and ICD-10.

Type of service Begins Ends Prior authorization
Inpatient Admission on or after 10/1/15 Discharge on or after 10/1/15 Prior authorizations must be requested with ICD-10 codes.
Inpatient with known discharge date Admission before 10/1/15 Known discharge on or after 10/1/15 Prior authorizations must be requested with ICD-10 codes.
Inpatient with unknown discharge date Admission before 10/1/15 Unknown at the time of admission but discharge is on or after 10/1/15 Prior authorizations must be requested with ICD-9 codes. Prior-Authorization would be valid for entire admission.
Outpatient Services on or after 10/1/15 Not Applicable Prior authorizations must be requested with ICD-10 codes.
Long-term outpatient Services begin before 10/1/15 Services end on or after 10/1/15 Prior authorizations requested in ICD-9 will be valid for services on or after 10/1/15.

What changes has Keystone First made regarding subcontract and/or vendor claim processes to accommodate ICD-10?

Our ICD-10 Governance Committee has remediated the data intake processes to account for ICD-9 and ICD-10 claims received from vendors and subcontractors (e.g., MTM, LogistiCare, VSP, etc.). Additionally, we have received a letter of attestation from each vendor/subcontractor stating they are compliant and ready for ICD-10.

Is Keystone First monitoring the readiness of its providers?

We have, and will continue to engage providers until the October 1, 2015, implementation date to measure provider readiness through testing activities and direct correspondence.

Will Keystone First accept ICD-9 codes after October 1, 2015, for dates of service prior to October 1, 2015?

Yes. We will be able to process both ICD-9 and ICD-10 codes. ICD-9 codes should only be submitted on claims with dates of service prior to October 1, 2015. Current regulations require the use of ICD-9 codes for dates of service prior to October 1, 2015. Inpatient claims with discharge dates on or after October 1, 2015, must be coded in ICD-10. This will require the submission of two separate claims. All outpatient and professional claims with dates of service on or after October 1, 2015, must contain ICD-10 diagnosis codes.

Will Keystone First process provider claims using the code applicable to the date of service?

Yes. We will process claims using the code applicable to the date of service.

Will there be a grace period for providers to submit ICD-9 and/or ICD-10 codes? If yes, what is the grace period?

At this time, Keystone First is planning to follow the state's guidelines and approach for ICD-9 and/or ICD-10 grace periods.  Keystone First has not received any formal communications from the Department of Human Services (DHS) regarding a grace period. Example: If the state determines that, effective 10/1/2015, all claims with a DOS of 10/1/15 must have an ICD-10 code; Keystone First intends to follow the same approach with no grace period. If a state is not yet ready for full ICD-10 compliance and is allowing a grace period, Keystone First intends to follow accordingly.

How does the ICD-10 implementation impact providers who file paper claims?

The method used to submit the claim has no impact on the code set contained on the claim. The ICD-10 code set must be used on all claims with dates of service on or after October 1, 2015, and inpatient claims with a date of discharge on or after October 1, 2015. For dates of service or dates of discharge prior to October 1, 2015, a separate claim using ICD-9 codes must be submitted.

Will Keystone First change its medical policies with ICD-10 codes prior to October 1, 2015?

Keystone First medical policies have been updated to include the ICD-10 code set. The medical policy located on Keystone First’s website will be updated throughout July and August 2015 in preparation for the ICD-10 implementation date of October 1, 2015. Policy updates will be effective October 1, 2015.

Will Keystone First require the execution of new contracts or contract addendum?

Contracts are currently being reviewed to determine if any updates are required to accommodate ICD-10.

How will Keystone First communicate with providers about the ICD-10 transition?

Keystone First has developed a detailed month-by-month provider communication strategy for 2015. The provider communications team will engage providers on a monthly basis in addition to the ongoing ICD-10 provider testing in progress. We will inform providers of professional training resources available and direct providers to the CMS website for additional information. Keystone First will focus on educating providers on our ICD-10 timeline, testing status and instructions on submission of claims with ICD-9 and ICD-10 codes with dates of service that span the October 1, 2015, compliance timeline.

In reference to grouping ICD-10 coding to a DRG, will your organization be utilizing a third-party encoder?

Yes, we will be using Optum as the third-party encoder.

What DRG grouper will you be using for your claims?

Keystone First is currently monitoring the state's communications for the latest information regarding their intent to implement a new DRG grouper.  Keystone First encourages providers to visit the state's website for the latest DRG plans.

How would you handle unspecified diagnosis codes if no specific information is provided by the ordering physician?

Claims submitted with unspecified, non-billable ICD-10 diagnosis codes will be rejected.

Can we wait and move directly to ICD-11?

No. We may not wait for ICD-11. We must move to ICD-10 by the government-mandated date. ICD-11 has been delayed until at least 2017 by the World Health Organization (WHO), and transition to ICD-11 in the United States is unlikely to happen in the near future because of the modifications that may be necessary to make the United States ready for ICD-11.

What if I have questions about which ICD-10 code to use?

CMS has created General Equivalence Mappings (GEMs) to help providers translate ICD-9 codes to ICD-10. Reference the GEM FAQ for any questions you may have.

Additional questions?

If you have additional questions about Keystone First's transition to ICD-10, please submit your questions using our secure contact form.

Note: Be sure to select "Provider — ICD 10 Questions" from the Subject dropdown box.