ICD-10 Update

Legislation was passed for the ICD-10 effective date to be October 1, 2015. PreferredOne has continued its efforts preparing for ICD-10 including upgrading systems, end-to-end testing and revenue neutral analysis. See below for more information.

The transition of the ICD-9 code sets used to report medical diagnoses and inpatient procedures to the ICD-10 code sets is going to change how you do business, but that change doesn't have to be overwhelming. PreferredOne has provided below valuable links and resources to help you prepare for the transition to ICD-10. We will continue to update the website as information becomes available.


New! May 19, 2015: "ICD-10 Implementation Guidance"

Free webinar presented by CMS and sponsored by the Minnesota ICD-10 Collaborative Registration Information

November 5, 2014: "Transitioning to ICD-10"

Presented by CMS/Medical Learning Network Presentation

September 4, 2013: "Coding Accuracy: Provider Perspective"

90 minute free webinar presented by the Minnesota ICD-10 Collaborative Presentation

October 9, 2012: "The Winding Road to ICD-10 Codesets"

Presented by the Minnesota ICD-10 Collaborative Presentation

Understanding the Basics

These fact sheets will introduce you to ICD-10, explain why it’s necessary, and give you the information you’ll need to get started on your transition. The Centers for Medicare & Medicaid services (CMS) website has numerous resources available including the following:

CMS has partnered with PAHCOM, the Health Resources and Services Administration, the National Association of Community Health Centers, and the National Association of Rural Health Clinics to offer a series of webinars for providers on preparing for ICD-10. Recordings of these webinars are available on the CMS YouTube channel:

ICD-10 Resources: Get on the Road to 10

Implementation Guides

These CMS implementation guides, checklists, and timelines will provide you with step-by-step guidance through the ICD-10 implementation.

The ICD-10 implementation guides provide detailed information for planning and executing the ICD-10 transition. The landing pages to multiple links to creating roadmaps, planning, analysis, design, development testing, implementation and timelines by type of provider are below:

  • Small Practices
  • CMS Releases "road to 10" Online Resource for Small Practices

    CMS "Road to 10", is an online resource built with the help of providers in small practices. This tool is intended to help small medical practices jumpstart their ICD-10 transition. "Road to 10" includes specialty references and gives providers the capability to build ICD-10 action plans tailored for their practice needs

  • Medium Practices
  • Small Hospitals
  • Payer

ICD-10 FAQ's From Providers

Q: Is PreferredOne ready for ICD-10?

A: Yes, systems have been upgraded to be able to receive ICD-10 and testing is ongoing.

Q: When should providers begin billing PreferredOne the ICD-10 codes?

A: ICD-10 procedure and Diagnosis Codes for Services & discharges with dates of service 10/1/2015 and beyond.

Q: Will PreferredOne still accept ICD-9 codes after 10/1/2015?

A: ICD-9 procedure and diagnosis codes for services with dates of service PRIOR to 10/1/2015 will continue to be accepted. Claims with ICD-9 procedure and diagnosis codes for services and discharges with dates of service 10/1/2015 will be rejected.

Q: Will PreferredOne use any type of map or crosswalk from ICD-9 to ICD-10 or vice versa?

A: No crosswalk ICD-9 to ICD-10 or ICD-10 to ICD-9 codes will be used for adjudicating claims. Maps will be used to model financial neutrality.

Q: Can both ICD-9 and ICD-10 codes be submitted on the same claim?

A: No, PreferredOne will not accept both ICD-9 and ICD-10 codes on same claim.

Q: When will PreferredOne begin testing for claims activity?

A: PreferredOne is targeting testing with some direct trading partners and some clearinghouses by 1st quarter 2015. We will communicate results on the website or provider newsletters.

Q: Are coverage policies going to be updated with new codes?

A: PreferredOne coverage policies do not reference specific diagnosis codes, so there is no intent to change coverage policies based on the change to ICD-10 codes. Any updated medical policies will be communicated via the provider bulletins.

Q: Will you renegotiate the contract to replace ICD-9 codes with ICD-10 codes? If so, when will you renegotiate, and what will you do if renegotiation does not occur until after the switch over to ICD-10?

A: Provider contracts may be updated to remain budget neutral. This should be discussed with your contract manager.

Q: When will any updated policies be available?

A: Updated medical, coding and payment policies will be communicated by 2nd quarter 2015.

Q: How will providers receive updated communication on ICD-10?

A: Additional provider communication will be via the website or provider newsletters.

Q: Are you making changes to the GEMs/reimbursement mapping provided by CMS?

A: Yes, we will be using a 3M mapping product.

Q: To what degree will the transition impact managed care rate schedules?

A: PreferredOne does not have separate schedules for managed care.

Q: When should prior authorizations begin using ICD-10 codes?

A: ICD-9 codes should continue to be used for prior authorizations made until 9/30/2015, regardless of the date of service (for example, a call into PreferredOne made on 9/1/2015 for a service taking place 11/1/2015 should still use ICD-9 codes). ICD-10 codes should be used for prior authorizations made beginning 10/1/2015. Prior authorizations submitted and approved prior to 10/1/2015 with ICD-9 codes do not need to be resubmitted if the service is occurring after 10/1/2015.

Q: Will PreferredOne reimburse non-specific ICD-10 diagnosis or procedure codes?

A: The main intent of ICD-10 is to be more specific, but there are some cases where non-specific codes are possible. Non-specific ICD-10 diagnosis or ICD-10 procedure codes submitted on either HCFA or UB claim forms will be reviewed on a case by case basis to determine if reimbursement is appropriate. If there is a more specific code available, the claim may be denied and returned to provider. Medical records may be requested to substantiate billing.

Q: For 10/1/2015 inpatient discharges, how will claims be adjudicated since DRG grouper V32 is used, which is not ICD-10 compliant?

A: On 10/1/2015, inpatient claims will be grouped using the new ICD-10 compliant DRG grouper V33. Inpatient reimbursement will be based on DRG V32 weights and rates.

Q: How do you plan to manage capitation reconciliations?

A: PreferredOne does not have capitation agreements.

Q: Will outpatient APC grouper claims be impacted on 10/1/2015?

A: Outpatient APC claims will be grouped and priced utilizing the same grouper, methodology and reimbursement throughout the year. Benefit impacts will still apply.

Q: Does PreferredOne anticipate any delays with claims adjudication as a result of ICD-10?

A: We do not foresee any delays in adjudication from the health plan perspective.

Q: Will any timely filing deadlines be extended as a result of ICD-10?

A: No, Timely filing deadlines will remain the same. However, issues beyond the provider's control such as clearinghouse or software upgrades will be considered on a case-by-case basis. As always, let your provider representative know as soon as you see any issues with your systems or transmissions.

Q: How will you handle payment provisions of contracts that are diagnosis based?

A: Contracts are not dependent on diagnosis at this time. Member benefits are and will be crosswalked.

Q: How long will it take to implement the version compatible with ICD-10 Codes?

A: We have been working on this for several years and will be ready to go live by the 10/1/2015 date.

Q: What is the earliest date(s) that the current software version can be upgraded to accommodate the ICD-10 code sets?

A: Our claims software version is currently upgraded to accommodate the ICD-10 code sets.

Q: What are your plans to manage potential problems related to network connectivity, processing time and overall integration, since there will be a period where you’ll be simultaneously processing ICD-9 and ICD-10 claims that will have very different IT processing requirements, given the differences in the amount of data, complexity, etc.?

A: This is part of end-to-end testing. The claims system is being tested to ensure that it can handle processing of both ICD-9 and ICD-10 correctly based on the date of service. We are testing with the clearinghouses as well.

Q: Will you share the result of internal processing for transactions (true end-to-end testing)?

A: General findings will be posted on the website, not specific to any provider.

Q: If ICD-10-codes are to be used, will the payer give the provider a copy of the new grouper logic?

A: Grouper logic is based according to CMS specifications in their final rules.

Q: Why is CMS not allowing dual coding?

A. With the ICD-10 deadline approaching, many small physician offices have yet to prepare for the transition. Initially, a dual coding system was proposed to help unprepared practices sail through revenue disruptions. As a part of this system, practices would have been allowed to submit claims coded in ICD-9 or ICD-10 during the transition period.

However, in February 2015, a revised guidance statement was released by CMS which explained that the dual processing of ICD-9 and ICD-10 codes would not be allowed for practices. This is because majority of payers and providers have already adopted IT systems that will accept new ICD-10 codes. According to the CMS, providers can run their medical practice effectively by utilizing a single coding standard. To ensure timely payments post ICD-10 implementation, many practices are opting to outsource the coding and billing needs to third parties.

Q: What is the contingency plan if all claims fail?

A: PreferredOne is doing everything possible to prevent this. We have been preparing and conducting tests in preparation for ICD-10, and do not anticipate that a contingency plan will need to be invoked. As always, let your provider rep know as soon as you see any issues with your systems or transmissions. Claims can still be processed manually if necessary.

Q: Are there plans to ramp up staffing so needs are met?

A: At this time, PreferredOne is not planning on increasing staff specific to ICD-10 beyond what was done to prepare for ICD-10, and will continue to evaluate the need. PreferredOne is preparing to monitor incoming claims for early identification of any abnormal issues as well as training existing staff to be available to support. There will also be an internal team available to help troubleshoot issues that arise during the transition.

Q: Will claims potentially be held up?

A: PreferredOne does not anticipate any hold up for claims for ICD-10 at this time. This could be an issue with either provider or health plan. There is always a potential for any claim to be held up for a variety of reasons, not just specific to ICD-10.

Q: How should we bill claims that have dates that cross 9/30/2015 into 10/1/2015?

A: This summer, CMS released MedLearn Matters bulletin SE1408 to clarify language under “Claims that Span the ICD-10 Implementation Date”. Please note that PreferredOne is following CMS guidelines when claims span the ICD-10 implementation date for institutional, professional, and supplier claims.

For example, a patient may be admitted inpatient September 29, 2015, and is discharged after October 1, 2015. Another example may be a patient is in the ER or in observation September 30, 2015, and does not leave until October 1, 2015. The general rule: inpatient claims should be coded according to the discharge date.

All outpatient and physician claims should be split based on date of service. So for example, if a physician provides E/M inpatient professional services September 29, 2015 – October 2, 2015, the claims should be split where ICD-9 codes are used for September 29-30 dates of service, and a second claim should be submitted where ICD-10 codes are used for October 1-2 dates of service.

*New* PreferredOne has contacted the providers selected for testing ICD-10, and is in the process of testing end-to-end and revenue neutral. We will post results here in the near future. Additional providers who have requested testing may be considered at a future date.

Implementation Testing

Revenue testing is considered the financial analysis to remain revenue neutral throughout this process. This involves providers natively coding claims directly from the medical chart using ICD-9 and ICD-10 procedure and diagnosis codes for selected scenarios/claims.

End-to-end testing is considered testing to make sure the claims with ICD-10 will be accepted either directly or via clearinghouse into our claims processing system, adjudicated appropriately and returned to the provider successfully. The testing of clearinghouses needs to be initiated by the provider since PreferredOne works with a variety of them and they are limited in what they are able to do.

Both revenue neutral and end-to-end testing involve significant resources by both the health plan and providers. As a result, in both testing approaches, PreferredOne will work with selected providers to work through the testing. Please complete the survey below so that the ICD-10 selection team can evaluate all responses. Selected providers will be contacted directly.

Begin Survey

ICD-10 Testing Survey

If you are a provider interested in ICD-10 testing, please complete the following survey and click on the submit button when finished. Selected providers will be contacted directly.

PreferredOne ICD-10 End-to-End Testing and PreferredOne ICD-10 Readiness:

PreferredOne has successfully completed ICD-10 testing of systems. PreferredOne selected a few clearinghouses and five providers, with varying types of service to participate in ICD-10 end-to-end testing. Overall, participants were able to successfully submit ICD-10 test claims and have them processed through PreferredOne claim systems. In addition, the providers received Remittance Advices (RAs) successfully. An acceptance rate of 99.6% was achieved. 11% of the claims were rejected due to invalid submission of ICD-10 codes. Inpatient, Outpatient, Surgery Center, and Physician claims were tested. Testing demonstrated that PreferredOne systems are ready to accept ICD-10 claims, and able to adjudicate and return claims both directly or through a Clearinghouse to meet the upcoming deadline.