ICD-10

The U.S. Department of Health and Human Services (HHS) issued a rule July 31, 2014 finalizing October 1, 2015 as the new compliance date for healthcare providers, health plans, and healthcare clearinghouses to transition to ICD-10, the tenth revision of the International Classification of Diseases.

On this page:

If you have questions regarding PacificSource and ICD-10 that are not answered on this page, please contact your Provider Service Representative (view directory). 

Introduction


What is ICD-10?

 

The International Classification of Diseases (ICD-10) is a system for statistical classification of disease published by the World Health Organization. It's one of several means for reporting procedures performed in acute care facilities.

ICD-10 code sets have been widely used internationally for more than a decade to report patient health conditions. They're also used for mortality reporting in the United States. The U.S. currently uses ICD-9 coding both to report patient health conditions and facilitate claims processing and provider reimbursement.

The U.S. Department of Health and Human Services (HHS) has mandated use of ICD-10 codes in the United States on all HIPAA transactions by October 1, 2015, for both reporting and payment of claims.

The following information should be used by providers and vendors to stay updated on PacificSource's ICD-10 status. This page will be updated quarterly.

Project Status


What is the status of PacificSource's compliance process?

 

ICD-9 to ICD-10 translations has been finalized. Remediation has been finalized. End-to-end testing is in progress.

 

What software will PacificSource be using for processing ICD-10 codes?

 

We are using an ICD-10 compliant claims processing system.

 

Does PacificSource plan to participate in end-to-end testing?

 

Yes, testing remained open through 2014. Please see our testing plan for more details. 

As of January 2015, testing has been limited to our top claim submitters. Testing outside of this will be approved on a case-by-case basis with testing results posted to this site. We are encouraging all providers to test directly with their contracted clearing house. If you have additional questions, please contact your Provider Service Representative (view directory). 

 

When was PacificSource ready for end-to-end testing?

 
We became ready for end-to-end testing on January 2, 2014.

 

Who has PacificSource successfully tested ICD-10 files with?

 
Providers: 
  • Luke's Magic Valley Regional Medical Center
  • Rogue Valley Medical Center
  • Sacred Heart River Bend
  • Sacred Heart University District
  • PeaceHealth Southwest Medical Center
  • OHSU
  • St. Charles Health System
  • Slocum
  • Legacy Emanuel Hospital and Health Center
  • Oregon Medical Group
  • Apria HealthCare (DME provider)
  • Northwest Anesthesia Physicians
  • OHSU Anesthesia
  • Carson Tahoe Regional Medical Center
  • Saint Alphonsus Regional
  • Gardnerville Walmart Clinic
  • BMH Strawberry Wilderness
  • Blue Mountain Hospital
Clearinghouses:
  • Emdeon Clearinghouse 
  • RelayHealth Clearinghouse
  • Office Ally Clearinghouse
  • GateWayEDI Clearinghouse

 

What are your project milestones?

 

October 2012: PacificSource ICD-10 project launched.

September 2013: ICD-9 to ICD-10 translation was completed.

January 2014: Systems remediated.

January 2014: End-to-end testing began with vendors and providers. 

October 1, 2015: ICD-10 compatible processes go into production. ICD-9 codes with dates of services beyond the go-live date will not be processed.

 

 

Before and After the Go-live Date


Is PacificSource sponsoring any programs to help providers get ready for ICD-10?

 
 

We have partnered with a local AAPC ICD-10 chapter to provide discounted training. View the flier >

Will PacificSource follow the "CMS and AMA Announce Efforts to Help Providers Get Ready For ICD-10" guidance released from CMS on July 6, 2015?

 
 

We will follow our own standard policy and procedures with consideration of CMS guidelines

Will this impact Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), or Current Dental Terminology (CDT) procedural coding?

 
 

No, you will continue to use valid CPT, HCPCS, and CDT codes as you do today.

Will PacificSource accept ICD-9 codes after the CMS ICD-10 go-live date?

 
 

No, PacificSource is a HIPAA covered entity and required to follow CMS guidelines. All claims submitted with dates of service on or after the CMS ICD-10 go-live date will need to use ICD-10 codes. If CMS were to change their timeline, Pacificsource would change to accommodate the new CMS timeline.

If my transition to ICD-10 didn't go well, how do I submit claims to PacificSource?

 
 

Through InTouch for Providers, our secure online portal, you can enter claims for electronic submission. If you need additional assistance with this process, please contact your PacificSource Provider Representative.

For additional CMS claims submission options, please see the MLN Matters article, "Claims Submission Alternatives for Providers Who Have Difficulties Submitting ICD-10 Claims." >

How will PacificSource manage referral and preauthorization requests spanning the CMS ICD-10 go-live date?

 
 

All referrals and authorizations submitted before the CMS ICD-10 go-live date will need to use ICD-9 codes, regardless of the date of service. All referrals and authorizations submitted on or after the CMS ICD-10 go-live date will need to user ICD-10 codes, regardless of the date of service. The time of submission defines what code set you use, not the date of service. 

How will PacificSource handle hospital claims that span the ICD-10 implementation date?

 
 

We will follow the CMS guidelines listed in Medical Learning Network (MLN) Matters.

Single item services whose time-frame cross over midnight on the day before the CMS ICD-10 go-live date (e.g., Emergency Room Visits and Observation) are not split into two separate charges, rather the single item service should be placed in the claim based upon the Line Item Date of Service as stated in the CMS MLN Matters;

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1325.pdf

Single Item Services:

Inpatient Claims - If the inpatient claim spans the implementation date of ICD-10, the entire stay should be coded with ICD-10 codes and the discharge date will be used for the processing of the claim. Please see above MLN matters link for additional information.

Emergency Room Encounters - Single item services spanning the ICD-10 transition date will be consolidated into one claim using ICD-9 codes. Emergency Room services use the date the patient enters the ER.

Example: If a patient arrives at 11:00 p.m. on the day before the CMS ICD-10 go-live date, and is seen by the ER physician and has an x-ray and lab prior to midnight, you would bill the professional fees, x-ray, and lab on a claim for date of service the day before the CMS ICD-10 go-live date. Then at 12:30 a.m. on the day of the CMS ICD-10 go-live date it is decided that the patient needs additional labs and a CT scan, these services are billed on a second claim with the date of service of the CMS ICD-10 go-live date. 

Observation Encounters - Observation services use the date the observation begins. 

Example: A patient arrives in the ER at 8:00 p.m. on the day before the CMS ICD-10 go-live date. They have labs and an MRI. It's determined at 10:00 p.m. that the patient needs to be admitted to observation and is in observation for ten hours. This claim will be billed for the ER fees, labs, an MRI, and observation ten units for date of service of the day before the CMS ICD-10 go-live date. At 6:00 a.m., labs are repeated. The patient is doing much better and is released at 8:00 a.m. the following day. This claim will be billed with the repeat labs only with a date of service of the CMS ICD-10 go-live date.

The MLN Matters contains a table with split billing instructions for all types of institutional and professional services for ICD-10 implementation. PacificSource will follow CMS guidelines and instructions for these types of services.

How will PacificSource handle professional claims that span the ICD-10 implementation date?

 
 

Professional claims will need to be split billed by the provider. Services provided prior to the implementation date need to be billed with ICD-9 codes. Services provided on or after the implementation date need to be billed with ICD-10 codes. PacificSource will not accept a claim containing both ICD-9 and ICD-10 codes.

How will PacificSource manage professional claims that must be billed on paper after the April 1, 2014, cutoff date?

 
 

PacificSource will require all professional paper claims to be billed on the new CMS-1500 form. This form was approved Monday, June 17, 2013. Changes to this form are identified here by NUCC.

Will unspecified codes have a place in ICD-10 and with PacificSource?

 
 

We are following the CMS guidelines around ICD-10. The CMS newsletter states the following about unspecified codes.

Sign/Symptom/Unspecified Codes

"In both ICD-9-CM and ICD-10-CM, sign/symptom and "unspecified" codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient's health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter.

If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information isn't known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate "unspecified" code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). In fact, unspecified codes should be reported when they are the codes that most accurately reflects what is known about the patient's condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code."

Provider Information


What steps do providers need to take to be ICD-10 ready?

 

The Centers for Medicare and Medicaid Services (CMS) has a library of resources for providers. To find out what steps you should be taking, visit the CMS website or the Road to 10 site, which was designed to assist small providers preparing for ICD-10.

ICD-10 Resources


We're just getting started.

 

Our project is underway.

 

We're ready to talk to vendors.