Q. What are the benefits of going to ICD-10?

A: The move to ICD-10 is a big change for both CCHP and healthcare providers. This effort is well worth it, as moving to the ICD-10 system will help the industry to respond to multiple challenges in health care, including:

  • Mandates to continuously improve quality of care
  • Managing the cost of care
  • Keeping pace with innovation

Moving to the ICD-10 code set provides a number of additional benefits, including:

  • Improved patient care management
  • Greater specificity and efficiency for diagnosis identification
  • Better compliance with fraud and abuse monitoring
Q. Why implement ICD-10 now?

A: An important goal of the Affordable Care Act is to achieve greater financial efficiency and affordability within the U.S. healthcare system. ICD-10 codes allow for more specific and descriptive diagnosis coding by the expansion of extra digits in their structure, to allow for a more detailed and accurate code selection to describe each patient’s medical care.

The new system also allows for growth in cataloging continued developments in medical procedures and diagnostics without the danger of running out of available code numbers like the ICD-9 code set is experiencing now.

Q. What is the transition date to ICD-10?

A: October 1, 2015.

Q. How can we prepare for ICD-10 compliance?

A: Children’s Community Health Plan (CCHP) has analyzed ICD-10 impacts and encourages all stakeholders to do the same to ensure their readiness for ICD-10 compliance. Stakeholders and providers can utilize CCHP ICD-10 Testing and Centers for Medicare and Medicaid Services (CMS) ICD-10 resources to assist with readiness.

Q: Who does the ICD-10 code set transition impact?

A: The transition to the ICD-10 code sets is a CMS mandate and impacts all HIPAA-covered entities, including Medicaid, Medicare, and all other payers as well as providers and billers.

Q: What should providers do in order to prepare for the conversion and avoid lapses in reimbursement?

A: Industry advice is for practices to talk now with their banking partners to set up a contingent line of credit to prepare against a temporary disruption in their payment flow. CCHP will do everything possible to minimize the impact of the transition, but it would be prudent for providers to plan ahead.

Q: When will CCHP be ready to accept ICD-10 codes?

A: CCHP is ready to accept ICD-10 codes on the compliance date, October 1, 2015.

Q: What type of rejection will be sent if claims with date of discharge October 1, 2015, and after are not sent with ICD-10 codes after the compliance date? 

A: Providers will receive a front-end, claim level rejection.

Q. Will there be changes to payments based on diagnosis?

A: There will no doubt be changes to payments; however, CCHP completed an analysis of DRG-related shifts using 2012 claims data from SSM-Madison, SSM-Janesville and St. Clare Hospitals. This analysis indicated the overall impact should result in less than a 4 % variance to payments overall. CCHP is still in the process of completing our analysis of smaller Rural or Critical Access Hospitals in our coverage area.


Q. How do we update our software to accommodate ICD-10 changes?

A: Each Health Insurance Portability and Accountability Act of 1996 (HIPAA)-covered entity (providers, payers, and clearinghouse) is responsible for understanding how ICD-10 will affect them, including software impacts, and prepare accordingly.  Providers that contract with a software vendor are encouraged to contact that entity regarding its ICD-10 preparedness.

Q. Is there a sample CMS 1500 claim form (02/12) that can be emailed which provides an example of how to complete the form after October 1, 2015?

A: Chapter 26 of the Medicare Claims Processing Manual describes how to complete a CMS-1500 form.


Q. Will our business use all of the new ICD-10 codes?

A: Not all 68,000 diagnosis codes will be used by your practice. 

Q. Are ICD-10 diagnosis codes all new codes or will some remain the same as the current ICD-9 diagnosis codes?

A: The ICD-10 diagnosis codes will replace the current ICD-9 diagnosis codes; therefore, CCHP will require ICD-10 diagnosis codes and ICD-10 surgical procedure codes to be indicated, when applicable, on claims when the date of discharge is October 1, 2015, or after.

Q. How is the ICD-10 code set different than the ICD-9 code set?

A: The ICD-9 codes are primarily numeric and have three to five digits; whereas ICD-10 codes are alphanumeric and contain three to seven characters. Furthermore, the descriptions between the code sets are different.

Q. Will outpatient and office procedure codes be changing?

A: The transition to ICD-10 for diagnosis coding and inpatient surgical procedure coding will not affect the use of CPT or HCPCS for outpatient and office coding.  Your practice will continue to use existing CPT and HCPCS codes.

Q. Will we still need to provide the "zz" qualifier in box 24i and the taxonomy code in boxes 24j and 33b for paper claims?

A: All of the existing rules are still required.

Q. Can a claim contain both ICD-9 and -10 codes?

A: No. A claim must contain only ICD-9 or only ICD-10 codes. The code set used must be consistent with the date of discharge: ICD-9 codes for date of discharge 9/30/15 and prior; ICD-10 codes for date of discharge October 1, 2015, and after.

Q. Will you accept both ICD-9 and ICD-10 claims in the same file?

A: Mixed code sets in a single file (EDI 837) can be processed, as long as each claim contains a single code set. Remember that a single claim CANNOT contain mixed code sets.

Q. Will CCHP be accepting all ICD-10 codes (not just a partial set)? How will CCHP handle the use of unspecified codes?

A: CCHP will be accepting most ICD-10 codes. CCHP is following Centers for Medicare and Medicaid Services (CMS) guidance on the denial of unspecified codes.

Q. How do I find the ICD-10 codes for services our office provides?

A: Providers are responsible for ensuring the codes used are appropriate, valid, and the most specific code for a member’s condition or planned surgical procedure.

Q. Has CCHP used a crosswalk for ICD-9 to ICD-10 mapping?

A: CCHP initially used the CMS General Equivalency Mappings (GEMs) to provide our original ICD-10 mappings, and then completed reviews and editing of those suggested mappings to complete the translations. CCHP has implemented a code set management tool to assist us with on-going updates to code sets. The Centers for Medicare and Medicaid Services (CMS) website offers links to GEMs tools for providers.

Q. How should split claims (claims with dates of service prior to and after October 1) be coded?

A: CCHP is following CMS guidance on how split claims should be processed. Visit the Centers for Medicare and Medicaid Documentation for more information on the split claims process.

Q. What happens with auto authorizations?

A: If beginning date of service on the authorization is September 30, 2015, or prior, ICD-9 code set should be used. If beginning date of service on the authorization is October 1, 2015, or after, ICD-10 code set should be used.



Children's Community Health Plan

PO Box 56099
Madison, WI 53705

Together with CCHP

Children's Community Health Plan

PO Box 1997, MS 6280
Milwaukee, WI 53201


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