Frequently Asked Questions (FAQs) for ICD-10

Visit the CMS ICD-10 web site www.cms.gov/icd10 for the latest news and resources. Providers may also wish to sign up for CMS ICD-10 Industry Email Updates.

The ICD-10 compliance deadline is October 1, 2015. For services provided on or after October 1, 2015, the ICD-9 code sets currently used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. Transactions with a date of service of October 1, 2015 or after that contain ICD-9 codes will be denied.

Electronic claims including ePACES, without ICD-10 coding or that have invalid ICD-10 diagnosis and inpatient procedure codes for dates of service on or after October 1, 2015, will be rejected with a pre-adjudication edit.

Paper claims with the same diagnosis or procedure code errors will be denied.

It is the provider's responsibility to transition and train their staff on ICD-10 coding. The eMedNY Call Center will assist callers with rejected or denied claims, due to coding issues. However, the Call Center will be unable to check ICD-10 codes to determine validity prior to submitting claims.

No. The ICD-10 code sets are effective for dates of service on or after October 1, 2015. ICD-10 cannot be used on claims with a date of service or end date of service/discharge date prior to October 1, 2015.

All systems must be able to accommodate both ICD-9 and ICD-10 codes for all claims. ICD-9 coding is used for claims with dates of servicer prior to October 1, 2015 and ICD-10 for claims with dates of service on or after October 1, 2015.

No. Claims must be submitted according to the guidelines in this FAQ.

Claims containing both ICD-9 and ICD-10, where the Primary Diagnosis (based on Service Date), is not found in the ICD diagnosis group will hit edit 00146.

Claims containing both ICD-9 and ICD-10, where the Secondary Diagnosis (based on Service Date), is not found in the ICD diagnosis group will hit edit 00148.

Claims with procedure codes containing both ICD-9 and ICD-10 codes will hit edit 02087.

Yes. The ICD-10 code is entered in the same loop and segment as the ICD-9; however the code is identified as ICD-10 - using a different qualifier than has been used for ICD-9. The decimal continues to be implied for ICD-10 as it is in ICD-9 coding.

The qualifiers used for ICD-10 are listed below.

Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N.

"HI - HEALTH CARE DIAGNOSIS CODE."

Health Care Claim: Institutional (837), 005010X223.
Washington Publishing Company, May. 2006.
(http://www.wpc-edi.com) 185-243.

eMedNY does not publish ICD-9, and will not publish ICD-10. NY Medicaid will not crosswalk ICD codes.

There is ICD conversion information on the CMS website:
http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/icd10

Institutional Claims

If the claim is for Clinic APG Episode of Care or CHHA Episodic services with multiple dates of service where the through date is on or after October 1, 2015, the claim must be coded as ICD-10 for all dates of service - even if the episode started before October 1, 2015.

For other types of Rate Based Institutional claims that do not bill using from and through dates of service, providers must split their claims to separate ICD-9 claims (prior to October 1, 2015) from ICD-10 claims (on or after October 1, 2015).

For those Institutional providers who bill the first of the month subsequent to when the service was rendered. The ICD Version used is determined by the date of service as it appears on the claim. Therefore, services rendered in September 2015 that are billed as date of service October 1, 2015, must use the ICD-10 code set.

Professional Claims

Professional claims must be split to separate ICD-9 claims (date of service prior to October 1, 2015) from ICD-10 claims (date of service on or after October 1, 2015).

All paper claim forms must conform to the same instructions set forth for electronic claims.

DRG Inpatient claims which are rate codes 2946/2953 and GME 3130, should be coded according to the discharge date. If the discharge date is on or after October 1, 2015, the diagnosis and procedure codes must be ICD-10, regardless of the date of admission.

Non-DRG claims (except for psychiatric claims, discussed in FAQ ICD13) need to be split billed. Claims with dates of service prior to 10/1/2015 must contain ICD-9 codes and claims for dates of service on or after 10/1/2015 must contain ICD-10 codes. If the non DRG claim will be interim billed with no discharge date and the end date of service is on or after October 1, 2015, the coding must be ICD-10.

NOTE: This could result in a DRG claim coded as ICD-10 when the discharge date is on or after October 1, 2015 while the ALC portion of the stay is coded as ICD-9, because the ALC (which is non-DRG) occurred prior to October 1, 2015.

An Inpatient claim for Psychiatric services should be coded according to the discharge date. If the discharge date is on or after October 1, 2015, the diagnosis and procedure codes must be ICD-10, regardless of the date of admission.

If the claim is to be interim billed and does not have a discharge date, then the coding is dependent on the end date of service.

NOTE: When adding interim periods, if the original claim is coded as ICD-9 and the interim period to be added has an end date of service on or after October 1, 2015, then the adjusted claim with the added interim period will be coded as ICD-10.

Yes, the Diagnosis Code qualifier field will need to allow for the qualifier for either an ICD-9 or ICD-10 Diagnosis code to be reported, according to the Date of Service.

Trading Partners should refer to the NCPDP D.0 Companion Guide for further guidance.

There will be no changes to eMedNY paper claim forms. eMedNY will derive the proper ICD coding version based on the type of service and date of service.

However, providers must still separate the ICD-9 claims (date of service prior to October 1, 2015) from the ICD-10 claims (date of service on or after October 1, 2015), because the rule against mixing ICD-9 and ICD-10 on the same claim also effects paper claims.

PTE has been available since July 28, 2014 for ICD-10 testing.

Yes, in Test and Production.

eMedNY's Pre-Adjudication Crosswalk has been updated and provides the front-end responses that will be sent in the 277CA.

Please refer to:
https://www.emedny.org/HIPAA/5010/transactions/crosswalks/eMedNY%20Pre-Adjudication%20Crosswalk%20(837%20Health%20Care%20Claims).pdf

Paper claims will be denied with an adjudication edit on the remittance advice.

Yes. We strongly encourage trading partners to test their ICD-10 transactions before the compliance date.

eMedNY offers a live comprehensive Provider Test Environment (PTE) for trading partner end-to-end testing through the Medicaid claims adjudication process.

Using PTE, Medicaid trading partners can submit and test transactions until they achieve standards compliant transactions processed through our system.

The HIPAA Support Team can provide feedback and guidance until complete clean testing has been achieved. The HIPAA Support Team can be reached at emednyHIPAAsupport@gdit.com.

There is no ability for providers to submit a test via ePACES.

Upon implementation of ICD-10, providers will select the correct Diagnosis Code Version (ICD-9 or ICD-10) based on the date of service of the claim. The version button is in place and currently is defaulted to ICD-9. See the Version button on the "Diagnosis Tab".

Yes, in PTE 835 ERA's or paper remittances will be provided on the Monday following the date the test file was received.

PDF Providers will receive a paper remittance in testing.

NOTE: PDF is only available in production.

Yes, PTE has a strictly enforced limit of 2 files per day/per user and 50 transactions per file.

NYSDOH requires trading partners to be enrolled in NY Medicaid in order to submit any electronic transactions. Current trading partners will have the ability to test using PTE.

Please refer to the eMedNY Trading Partner Information Standard Companion Guide, which is available: https://www.emedny.org/HIPAA/5010/transactions/index.aspx

Remember to use the correct Test indicator to ensure test files are properly routed to PTE. Refer to Section 2.3.3 of the eMedNY Trading Partner Information Standard Companion Guide for further instructions, which includes NCPDP guidance.

Test data should be actual member data as the adjudication process in PTE does not support "dummy data". See section 2.3 Trading Partner Testing and Certification Process for complete details of the PTE: https://www.emedny.org/HIPAA/5010/transactions/eMedNY_Trading_Partner_Information_CG.pdf.

Yes, Providers may test independently from their clearinghouse.

NOTE: Providers must have their own submission method and ETIN in order to test.

eMedNY recommends testing the 837I, 837P, and 837D transaction sets, as well as NCPDP Batch 1.2 transaction sets.

When submitting test claims with ICD-10 codes submitters must use a date of service of October 1, 2015 or any date of service up to the date of the test submission. Future dates are not allowed.

Submitters who may be testing claims with ICD-9 codes must use a date of service prior to October 1, 2015.

Test results will be communicated in the same manner as the production environment submissions. It is the submitter's responsibility to interrogate each file returned by the eMedNY system (F-File, 277CA, 999, 835) to determine the compliance of their transactions. Submitters seeking guidance with corrective action may contact the HIPAA Support team at emednyHIPAAsupport@gdit.com.

NYSDOH does not require enrollment specifically for ICD-10 testing.

NYSDOH recommends the use of code R69 – Illness, unspecified.

If the claim is for Clinic APG Episode of Care with multiple dates of service where the through date is on or after October 1, 2015, the claim must be coded as ICD-10 for all dates of service - even if the episode started before October 1, 2015.

If the provider chooses to split an APG claim, the ICD-10 claim could fail with edit 2081 - All APG Lines Paid Zero.

No, ICD-10-PCS will be used to report hospital inpatient procedures only. The CPT and Healthcare Common Procedure Coding System (HCPCS) will continue to be used to report services and procedures in outpatient and office settings.

All providers who use ICD-9 coding are affected by ICD-10. Dental providers submitting claims to NY Medicaid are not required to report a diagnosis code.

If the provider is a Physician and has the Oral Specialty code and is billing for Oral Surgery then diagnosis code is required.

All providers who use ICD-9 coding are affected by ICD-10. Nursing claims are required to have a diagnosis code; therefore ICD-10 does affect the nursing claims. If a prior authorization begin date is on or after April 2, 2015 then contact the requesting physician for the ICD-10 procedure code. This will be utilized for claims with dates of service on or after October 1, 2015.

All providers who use ICD-9 coding, must be prepared to use ICD-10 coding starting with the date of service of 10/01/15.

ICD-10 coding applies to all providers who use ICD-9 coding currently. Primary Diagnosis is required for all Professional and Institutional claims.

When your office submits claims electronically, there is an ICD-9 code (except for dental claims).  Be sure to research the new ICD-10 code(s) for your office.

All data on TEST claims should be valid, except for the date of service which can be any date after 7/1/14.

All providers who use ICD-9 coding are affected by ICD 10. Providers must determine which ICD-10 diagnosis codes are applicable to the service rendered.