ICD-10 Top Ten List Information posted October 2, 2015

Note: This article applies only to claims submitted to TMHP for processing. Refer to the Medicaid managed care organizations (MCO) for information about benefits, limitations, prior authorization, reimbursement, and MCO specific claim processing procedures.

Note: For crossover claims for dual-eligible clients, providers must continue to follow standard billing guidelines for Medicare and Medicaid billing.

Effective October 1, 2015, TMHP will begin using diagnosis codes and surgical procedure codes from the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) as directed by the Centers of Medicare and Medicaid Services (CMS).

ICD-10 Codes

The ICD-10 classification system is significantly different from the ICD-9 system. It captures information in greater detail, and it can be expanded to work with future advancements in clinical medicine.

The following tables outline the differences between the ICD-9 and ICD-10 systems:

ICD-9 ICD-10

Limited data about clients medical conditions and hospital inpatient procedures

30 years old

Outdated terms

Inconsistent with current medical practice

Incorporates greater clinical detail and level of specificity to provider higher quality data.

Efficiently tracks health-care and public- health trends, quality-of-care issues, and the evaluation of health outcomes.

Used globally, so U.S. data can be included in world statistics and outcomes

No Laterality – Does not specify which side of the body the injury or condition is located.

Specifies where on the body the injury occurred; “Right” or “Left” account for more than 40 percent of codes.

Diagnosis Codes

ICD-9-CM ICD-10-CM

Structure of ICD-9 limits the number of new codes that can be created. Many ICD-9 categories are full.

3-5 digits

First digit is a letter (E or V) or a number

Digits 2-5 are numbers

Decimal is placed after the third character

Improved structure, capacity, and flexibility for capturing advances in technology and medical knowledge.

3-7 digits

Digit 1 is a letter; Digit 2 is a number

Digits 3-7 are alphanumeric

Decimal is placed after the third character

No placeholder characters “X” placeholders

14,567 codes 69,823 codes

Limited Severity Parameters Extensive Severity Parameters

Limited Combination Codes Extensive Combination Codes to capture complexity

On claims, enter the applicable ICD-9 indicator to identify which version of ICD codes is being reported

For Dates of Service 9/30/2015 and before, enter:

9= ICD-9-CM

On claims, enter the applicable ICD-10 indicator to identify which version of ICD codes is being reported.

For Dates of Service 10/1/2015 and after, enter:

0= ICD-10-CM

Surgical Procedure Codes

ICD-9-PCS ICD-10-PCS

3-4 digits 7 digits

3,882 codes 71,924 available codes

All numeric Alphanumeric (letters are not case sensitive and only letter U is not used).

Decimal after the second character No decimals

ICD-10 Coding for Claims Processing and Prior Authorizations

Providers may refer to the article titled “ICD-10 Coding for Claims Processing and Prior Authorizations,” which was published on this website on September 8, 2015, for more information.

Reminder: If difficulties should arise with a provider’s billing software, providers can log on to the secure TMHP portal using their previously-obtained log-on information and submit claims to TMHP using TexMedConnect. Providers can also submit claims to TMHP using the most appropriate paper claim form. Tips for TexMedConnect or paper claim filing:

To submit claims using TexMedConnect, providers must set up an account. Providers can refer to the Website Security Provider Training Manual on the Reference Material page of this website for instructions about creating an account.

Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 paper claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements.

Providers can refer to the Texas Medicaid Provider Procedures Manual, Section 6: Claims Filing for additional information about filing claims using TexMedConnect or a paper claim form.

Admit vs. Discharge

Inpatient claims with a date of discharge on or after October 1, 2015, will be reimbursed and processed using the rates that are in effect for the date of discharge and not the date of admission.

For example: If the inpatient stay was admitted on September 1, 2015, and discharged on October 1, 2015, TMHP would use the Diagnosis-Related Groups (DRG) relative weight and Standard Dollar Amount (SDA) based on the rate that was effective on October 1, 2015, not the rate that was effective on September 1, 2015.

Outpatient Observation and Private Duty Nursing

Claims must contain only ICD-9-CM diagnosis codes or ICD-10-CM diagnosis codes. For observation stays and Private Duty Nursing shifts that span the October 1, 2015, ICD-10-CM implementation date, two claims must be submitted:

The first claim must contain dates of service on or before September 30, 2015, and ICD-9-CM diagnosis codes.

The second claim must contain dates of service on or after October 1, 2015, and ICD-10-CM diagnosis codes.

Observation Period September 29, 2015 - October 1, 2015

Claim Submissions ICD Coding

September 29 - September 30 ICD-9

October 1, 2015 ICD-10

Private Duty Nursing Shift 7pm September 29, 2015 - 7 am October 1, 2015

Claim Submissions ICD Coding

7 p.m. to 11:59 p.m. ICD-9

12 a.m. to 7 a.m. ICD-10

TexMedConnect – ICD Qualifier

Effective August 28, 2015, acute care professional, institutional, and dental claims submitted via TexMedConnect will require providers to manually select the ICD-9 or ICD-10 diagnosis code qualifier. Updates to professional, institutional, and dental claim templates will be required to accommodate these changes.

Providers can refer to the article titled “Effective August 28, 2015, Acute Care Professional, Institutional, and Dental Claims Submitted Via TexMedConnect Will Require ICD Qualifier,” which was published on this website on July 24, 2015.

ICD-10 Implementation Web Page

The ICD-10 Implementation web page contains provider notifications for the ICD-10 benefit updates. The page also includes a link to the 2015 ICD-10 Bulletin, Special Bulletin No. 8

Benefit Updates

In preparation for the implementation of the ICD-10-CM diagnosis code changes, TMHP, the Texas Health and Human Services Commission (HHSC), and the Texas Department of State Health Services (DSHS) updated medical policies to include ICD-10-CM diagnosis codes effective for dates of service on or after October 1, 2015.

Diagnosis code limitations that are published in the Texas Medicaid Provider Procedures Manual and the CSHCN Services Program Provider Manual have been updated to the corresponding ICD-10-CM diagnosis codes

Providers can refer to the TMHP ICD-10 Benefit Updates web page for specific benefit changes to medical policies that identify the ICD-10-CM replacements for specific ICD-9-CM diagnosis codes.

Providers may refer to The General Equivalence Mappings (GEMs) posted on the Centers for Medicare and Medicaid Services (CMS) 2016 ICD-10-CM and GEMs web page for assistance in translating between the ICD-9 and ICD-10 Diagnosis Code Sets.

Note: Providers may refer to the CMS ICD-10 website for other resources for mapping diagnosis codes. Some professional organizations may also have mapping tools available. Please note that these mapping tools may result in different codes than those included in the TMHP ICD-10 Benefit Updates web page based on the policy review process.

Long Term Care (LTC)

Providers may refer to the Long Term Care home page on this website for LTC ICD-10 updates.

ICD-10 Compliant APR-DRG Grouper 32

Texas Medicaid is currently using ICD-10 compliant version 32 of the All Patient Refined-Diagnosis Related Groups (APR-DRG) system. Grouper version 32 APR-DRG information effective for dates of discharge on or after September 1, 2015, is available on Texas Medicaid Acute Care Hospital Reimbursement web page.

Inpatient claims with a discharge date before October 1, 2015, must be submitted with ICD-9-CM and ICD-9-PCS (inpatient procedure code) code sets. The claims will process using APR-DRG Grouper 32.

Inpatient claims with a discharge date on or after October 1, 2015, must be submitted with ICD-10-CM and ICD-10-PCS (inpatient procedure code) code sets. The claims will process using APR-DRG Grouper 32.

Note: When the Grouper is updated, providers must continue to submit inpatient claims with ICD-10-CM and ICD-10-PCS (inpatient procedure code) code sets. At that time, the claims will process using the updated APR-DRG Grouper.

Resources

State

Texas Medical Association (TMA)

Texas Hospital Association (THA)

HHSC Texas Medicaid and CHIP ICD-10 Information

Department of Aging and Disability Services (DADS) ICD-10 Information

Department of State Health Services (DSHS) ICD-10 Information

Department of Assistive and Rehabilitative Services (DARS) Early Childhood Intervention (ECI) Medical Diagnoses

Federal: Centers of Medicare and Medicaid Services (CMS)

Translating between the ICD-9 and ICD-10 Diagnosis Code Sets information can be found on The General Equivalence Mappings (GEMs) posted on the Centers for Medicare and Medicaid Services (CMS) 2016 ICD-10-CM and GEMs web page.

To help the health care industry prepare for ICD-10, CMS has developed an online ICD-10 implementation guide.

Providers may refer to the ICD-10 Page on the CMS website for more information.

Providers may refer to CMS ICD-10 Training information at CMS.gov.

In response to questions from the health care community, CMS has developed a Frequently Asked Questions (FAQ) document that provides clarification on the most commonly asked questions related to the ICD-10 implementation.

For more information, call the TMHP Contact Center at 1-800-925-9126.