ICD-10 Statement & FAQs

1199SEIU Benefit Funds’ ICD-10 Statement

Health Insurance Portability and Accountability Act of 1996 (HIPAA)-covered entities, including the 1199SEIU Benefit Funds, must adopt ICD-10-CM for diagnosis coding and ICD-10-PCS for procedure coding by October 1, 2015, per the U.S. Department of Health and Human Services’ final rules. To ensure there will be no disruption in operations, including claims processing and payment and prior authorization programs, we have developed and implemented a comprehensive plan to ensure that the Benefit Funds are ICD-10 compliant by October 1, 2015.

Goals

  1. For claims with dates of service or dates of discharge on or after October 1, 2015, to only accept and process ICD-10 transactions; and
  2. For claims with dates of service or dates of discharge prior to October 1, 2015, to continue to accept ICD-9-coded claims.

Our Preparations

We utilized the 3M Code Translation Tool to convert ICD-9 codes embedded in our documentation, rate agreements, forms, claims processing and medical necessity policies. We are also updating our inpatient hospital-payment methodology to an ICD-10-compliant grouper — specifically, MS-DRG Version 33.

We have engaged our test plans as scheduled and have tested our internal transactions as well as exchanged files with clearing houses, direct claims submitters, re-pricing entities and pre-authorization vendors. We expect to conclude testing by the end of August 2015.

ICD-10 FAQs

Claims Processing

Q1. What is the impact of ICD-10 conversion on provider reimbursement?
The conversion is being done to reflect new coding standards to more accurately capture patient status and care. While it is not intended to materially alter existing payments or reimbursements, some differences may result.

Q2. Will the Benefit Funds use a crosswalk for claims processing?
No. Claims with a date of service or a date of discharge on or after October 1, 2015, must be submitted with ICD-10 codes.

Q3. Will the Benefit Funds accept ICD-10 codes before the implementation date?
No. ICD-10 transactions will not be accepted before October 1, 2015.

Q4. Will the Benefit Funds continue to accept ICD-9 codes after the compliance date?
Yes, but only for claims with dates of service or dates of discharge prior to October 1, 2015.

Q5. Will the Benefit Funds accept the revised CMS/HCFA 1500 paper claim form version 02/12?
Yes, the Benefit Funds will accept and process paper claims submitted on both the 08/05 and the 02/12 versions of the CMS/HCFA 1500 form.

Q6. Will the Benefit Funds send 837 Transaction-set batches containing both ICD-9 and ICD-10 claims on or after October 1, 2015, to its re-pricing vendors?
Yes, the Benefit Funds will send 837 batches containing both ICD-9 and ICD-10 claims on and after October 1, 2015, and will also be able to receive such 837 batches from its re-pricing vendors.

Q7. Will the Benefit Funds accept 837 Transaction-set batches with both ICD-9 and ICD-10 claims spanning the conversion deadline?
Yes, the Benefit Funds will accept 837 batches with both ICD-9 and ICD-10 claims.

Q8. Will claims that don’t meet ICD-10 coding specifications be rejected at the point of receipt, or will a denial be issued?
Electronic claims that do not meet ICD-10 coding specifications will be rejected at the point of receipt from the clearinghouse. Paper claims that do not meet ICD-10 coding specifications will be denied, and a denial will be issued.

Q9. Can one claim be submitted with services that span the October 1, 2015, compliance date?
For outpatient service claims, the Benefit Funds will not accept claims with dates of service that span October 1, 2015. Similar to the Centers for Medicare & Medicaid Services, the Benefit Funds require providers to split the claim so that ICD-9 codes are billed on claims with dates of service September 30, 2015, and prior, whereas ICD-10 codes are placed on claims with dates of service October 1, 2015, and later. For inpatient service claims with dates of discharge on or after October 1, 2015, the entire claim is billed using ICD-10.

Q10. Will the Benefit Funds change its timely filing and claims resubmission process?
No. The Benefit Funds will continue to accept claims within one year of the dates of service or the dates of discharge. Claims submitted after one year of the dates of service or the dates of discharge will be rejected for timely filing. The Benefit Funds will continue to accept claims for reconsideration that are submitted within one hundred and eighty (180) days of the date of payment or the date of denial.

Authorizations

Q11. Will there be any changes to the pre-authorization procedures as a result of implementing ICD-10?
There will be no change to the Benefit Funds’ pre-authorization procedures. ICD-10 codes must be used for prior authorization requests submitted with dates of service on or after October 1, 2015.

Q12. For scheduled services, how far in advance of October 1, 2015, can you provide ICD-10 authorizations when the date of service is on or after October 1, 2015?
The Benefit Funds can accept ICD-10 authorizations for scheduled services as of August 1, 2015.

Q13. How will you handle authorizations of services that span the ICD-10 compliance date? For example, a claim receives an authorization for services prior to October 1, 2015, and the services span over October 1, 2015. Does a new authorization need to be obtained under these circumstances?
A new authorization is not needed by the Benefit Funds. However, for a date of service or a date of discharge on or after October 1, 2015, the claim must be submitted with ICD-10. (Please see response to Q9.)

Q14. Will case management/utilization review be required to use ICD-10 narratives for crossover continued-stay authorizations?
If the patient has an admitting ICD-9 code and is discharged on or after October 1, 2015, the provider must revise the admitting diagnosis to an ICD-10 code.

More Information

If you have questions about the Benefit Funds’ ICD-10 claims and authorization policies, please email them to ICD10@1199Funds.org.