Transitioning to ICD-10

Will Moda be ready for migration to ICD-10 on the ICD-10 implementation date?

Yes, Moda will be ready on the implementation date.

When will ICD-10 become effective at Moda?

Moda will adopt ICD-10-CM codes (diagnosis codes) effective Oct. 1, 2015, in conjunction with Centers for Medicare & Medicaid Services (CMS) and all other major payers. Claims for services prior to Oct. 1, 2015, must be submitted with ICD-9 diagnosis codes, and claims for services after Oct. 1, 2015, must be submitted with ICD-10 diagnosis codes Moda will adopt ICD10 codes effective with 10/1/2015 dates of service in conjunction with CMS. As the transition date nears, we will review CMS guidelines to determine if a grace period will be allowed and plan accordingly.

Will you allow ICD-9 and ICD-10 codes to be submitted on the same claim?

No.

How is Moda Health getting from ICD-9 to ICD-10?

Moda is using General Equivalency Mappings to map codes from one system to the other for all medical policies, payment policies, benefit applications, diagnostic edits and historical data tracking. Moda also will employ "intent mapping," in which the analyst compares ICD-9-CM codes to an expanded version of ICD-10-CM codes to identify all appropriate equivalent groupings. This way, Moda captures the intent of each code rather than simply creating a one-to-one crosswalk.

What 'claims scrubbing' edit changes will be made to Moda software to process ICD-10 claims? When will Moda be able to provide an explanation of how these new edits will impact operations?

Moda is working on remediating our claims processing for ICD-10 codes with the goal of changing claims processing as little as possible. We are staying consistent with our current ICD-9 edits, in that we require valid codes on claims. We will edit based on dates of service in accordance to CMS guidelines.

Why is CMS upgrading to ICD-10?

The healthcare industry is making the transition from ICD-9 to ICD-10 because:

What is different in ICD-10?

ICD-10-CM/PCS (International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System) consists of two parts:

ICD-10-CM is for use in all U.S. health care settings. Diagnosis coding under ICD-10-CM uses 3 to 7 digits instead of the 3 to 5 digits used with ICD-9-CM, but the format of the code sets is similar.

ICD-10-PCS is for use in U.S. inpatient hospital settings only. ICD-10-PCS uses 7 alphanumeric digits instead of the 3 or 4 numeric digits used under ICD-9-CM procedure coding. Coding under ICD-10-PCS is much more specific and substantially different from ICD-9-CM procedure coding.

Who needs to transition?

ICD-10 will affect diagnosis and inpatient procedure coding for everyone covered by Health Insurance Portability Accountability Act (HIPAA), not just those who submit Medicare or Medicaid claims. The transition will go much more smoothly for organizations that plan ahead and prepare now. The change to ICD-10 does not affect CPT coding for outpatient procedures.

What happens if we need to reprocess a claim after the Oct. 1, 2015, cutoff when the original process date fell before Oct. 1?

Diagnosis will still be date of service specific.

Will ICD-10 replace Current Procedural Terminology (CPT) procedure coding?

No. The switch to ICD-10 does not affect CPT coding for outpatient procedures. Like ICD-9 procedure codes, ICD-10-PCS codes are for hospital inpatient procedures only.

Will my payment change?

For providers, payment will continue to be based on your provider contract with Moda.

What happens if I don't switch to ICD-10?

Claims that do not use ICD-10 diagnosis and inpatient procedure codes on or after Oct. 1, 2015, cannot be processed. Moda will adopt ICD10 codes effective with 10/1/2015 dates of service in conjunction with CMS. As the transition date nears, we will review CMS guidelines to determine if a grace period will be allowed and plan accordingly.

Where can I find the ICD-10 codes?

The ICD-10-CM, ICD-10-PCS code sets and the ICD-10-CM official guidelines are available for free at:

They are also available through the CMS ICD-10 website at www.cms.gov/Medicare/Coding/ICD10/Index.html.

What changes do you anticipate in the authorization process?

Our intent is to have the authorization process work as closely as possible to the current process after the ICD-10 introduction.

When will changes to the authorization process be published and available?

We are not anticipating any further changes to our authorization process due to ICD-10.

Will there be changes in the code specificity requirements on authorizations?

Our current requirement is that provider's code to the highest level of specificity that can be determined at the time of each healthcare encounter. This requirement remains the same under ICD-10.

At what point will you require ICD-10 codes for authorizations?

We will require ICD-10 codes on or after the ICD-10 implementation date. Moda will adopt ICD10 codes effective with 10/1/2015 dates of service in conjunction with CMS. As the transition date nears, we will review CMS guidelines to determine if a grace period will be allowed and plan accordingly.

Will ICD-10 authorization requirements be based on date of service or the date of authorization?

They will be based on the date of service.

Where can I learn more?

ICD-10 resources are available through CMS, Medicare Administrative Contractors, professional associations and societies, such as AHIMA and the American Academy of Professional Coders, and practice management system/EHR vendors.

Visit CMS ICD-10 website for all things ICD-10, including the latest information on training opportunities.

Sign up for CMS ICD-10 email updates to receive the latest news and resources on ICD-10.

If you have further questions about Moda's process for migration from ICD-9 to ICD-10 diagnosis coding systems, please contact your Moda Provider Relations representative.

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