Provider Compliance with ICD-10

Date Issued: 9/1/2015

As previously communicated to all of our providers, The International Classification of Diseases (ICD) is replacing ICD-9 codes with ICD-10 codes effective October 1, 2015. The upgrade to ICD-10 allows for more detailed clinical documentation.

EmblemHealth will follow CMS guidance regarding the acceptance and adjudication of claims beginning on October 1. All claims for health care services performed on or after October 1, 2015 must use ICD-10 diagnosis codes. Claims that are not ICD-10 compliant will not be processed and will be returned to you for correction.

Are You Ready for ICD10?

If you haven’t already done so, please begin compliance testing within your practice and with your vendors to resolve any errors before the October 1 start date. This will ensure both you and your vendors are fully compliant and that all software is upgraded to accept the new codes so that there will not be any negative impact on your practice.

To review your readiness, the American Health Information Management Association (AHIMA) offers a comprehensive plan that includes a readiness assessment tool and a list of ICD-10 trainers certified by AHIMA.

You should continue to follow acceptable documentation practices that support your billed codes. For accurate reimbursement, statistical analysis and quality patient care, it is important that the ICD diagnostic code or value assigned to a provider’s clinical assessment match as closely as possible. The medical record is a legal document that needs to support the service billed and the reimbursement received.

Professional Providers to Use Revised CMS1500 Form (02/12)

We encourage you to submit your claims electronically. However, to avoid payment delays and re-work, if you submit paper claims, be sure to use the revised CMS1500 form (02/12) which supports the use of ICD10 codes. As of October 1, 2015, we will no longer accept claims submitted on the old CMS 1500 claim form (08/05). Claims submitted on outdated forms will be returned to you for submission on the correct form. Facility Providers continue to use Form UB04.

Submitting an ICD-10 Compliant Prior Approval or Referral Request

When submitting a prior approval or referral request, use the date that you are entering the prior approval or referral request (NOT the date of service) to determine whether to use ICD-9 or ICD-10 codes. Unless there are any new CMS guidelines, the following requirements apply with no exceptions.

  • For prior approval or referral requests entered before October 1, 2015, use ICD-9 codes only. Those submitted with ICD-10 codes will not be accepted and must be modified to use ICD-9 codes.
  • For prior approval or referral requests entered on or after October 1, 2015, use ICD-10 codes only. Those submitted with ICD-9 codes will not be accepted and must be modified to use ICD-10 codes.
  • Prior approval or referral requests submitted with a combination of ICD-9 and ICD-10 codes will not be accepted and must be modified to use either ICD-9 or ICD-10 codes (based on date of entry of prior approval request).

Visit our dedicated ICD-10 web page for more information and also see our FAQs. CMS also offers useful resources and FAQs.