ICD-10 Deadline and Testing Details Published by CMS

Posted by Mary Pat Whaley on August 4, 2014

On July 31, the Department of Health and Human Services (HHS) issued a rule (CMS-0043-F) finalizing October 1, 2015 as the new compliance date for health care providers and health plans to transition to ICD-10. ICD-10 represents a significant code set change that impacts the entire health care community.

When it comes to ICD-10, my general advice to practices is to “Forget About It” (until 2015.) You do need to understand the lingo, however, and make sure you have the basics down. If you’ve never explored your MAC website, now is a good time to do that. Sign up to get email notices from your MAC so you can be sure you won’t miss anything important.

But first, a little vocabulary for this article:

MAC = Medicare Administrative Contractor: this is the company that carries out Medicare’s instructions for accepting claims and approving claim payments. Some rules are set by Medicare for all MACs, but Medicare gives MACs some independence in setting their own rules. Just who is your MAC? Click on your state to find out who is your Part B (physician fee-for-service) Medicare administrator is on the Interactive Map Here.

DME = Durable Medical Equipment: items such as wheelchairs, crutches and splints.

NCD = National Coverage Determination: these are the rules that Medicare sets that all MACs must follow. Because the NCDs references diagnoses related to services, all NCDs will change with ICD-10.

LCD = Local Coverage Determination: these are the rules that Medicare allows each MAC to set themselves. Because the LCDs reference diagnoses related to services, all LCDs will change with ICD-10. These used to be called LMRP or Local Medical Review Policies.

FFS = Fee-For-Service: Reimbursement system where a separate payment is made to a health-care provider for each medical service rendered to a patient.

Trading Partner: An Electronic Data Interchange (EDI) Trading Partner is defined as any Medicare customer (e.g., provider/supplier, billing service, clearinghouse or software vendor) that transmits to, or receives electronic data from, Medicare.

RA = Remittance Advice: a paper or electronic document supplied by the insurance payer that provides notice of and explanation reasons for payment, adjustment,denial and/or uncovered charges of a medical claim. An ERA is an Electronic Remittance Advice. Sometimes it is called an EOB or Explanation of Benefits, although that term is used more frequently to describe the paper document that goes to the patient to describe how the payer has paid the provider/physician.

DRG = Diagnosis-Related Group: is a system to classify hospital cases into one of originally 467 groups, with the 467th group being “Ungroupable”.

As the ICD-10 implementation date of October 1, 2015, approaches, the Centers for Medicare and Medicaid Services (CMS) is taking a comprehensive four-pronged approach to preparedness and testing for ICD-10 to ensure that CMS as well as the Fee-For-Service (FFS) provider community is ready.

The four-pronged approach includes:

• CMS internal testing of its claims processing systems;
• Provider-initiated Beta testing tools;
• Acknowledgement testing; and
• End-to-end testing.

CMS Internal Testing of Claims Processing

CMS began installing and testing system changes to support ICD-10 in 2011. As of October 1, 2013, all Medicare FFS claims processing systems were ready for ICD-10 implementation. CMS continues to test its ICD-10 software changes with each quarterly release.

Provider-Initiated Beta Testing Tools

CMS recommends that you leverage the variety of Beta versions of its software that include ICD-10 codes as well as National Coverage Determination (NCD) and Local Coverage Determination (LCD) code crosswalks to test the readiness of your own systems. The following testing tools are available for download:

• NCDs converted from International Classification of Diseases, 9th Edition (ICD-9) to ICD-10 is located here. (Note: as of this writing there are only about 30 conversions published – you can easily scan down them to see if any will impact your practice and check back regularly over the next year.)
• The ICD-10 Medicare Severity-Diagnosis Related Groups (MS-DRGs) conversion
  project (along with payment logic and software replicating the current MS-DRGs),
  which used the General Equivalence Mappings to convert ICD-9 codes to International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM) codes, located here on the CMS website. (Note: this will not relate to physician practices.)
• A pilot version of the October 2013 Integrated Outpatient Code Editor (IOCE) that
  utilizes ICD-10-CM located here on the CMS website. This breaks ICD-10 into the following categories: Adult diagnoses, Newborn diagnoses, Pediatric diagnoses,
  Maternity diagnoses, Diagnoses for females only, Diagnoses for males only, Manifestation Diagnoses, and Mental health diagnoses. (Pretty cool, huh?) The final version of the IOCE is scheduled for release this/next month.

 Acknowledgment Testing

Providers, suppliers, billing companies, and clearinghouses are welcome to submit acknowledgement test claims anytime up to the October 1, 2015, implementation date. In addition, CMS will be highlighting this testing by offering three separate weeks of ICD-10 acknowledgement testing. These special acknowledgement testing weeks give submitters access to real-time help desk support and allows CMS to analyze testing data. Registration is not required for these virtual events.

All MACs and the DME MAC Common Electronic Data Interchange (CEDI) contractor will promote this ICD-10 acknowledgement testing with trading partners. This testing allows all providers, billing companies, and clearinghouses the opportunity to determine whether CMS will be able to accept their claims with ICD-10 codes. While test claims will not be adjudicated, the MACs will return an acknowledgment to the submitter (a 277A) that confirms whether the submitted test claims were accepted or rejected. MACs and CEDI will be appropriately staffed to handle increased call volume on their Electronic Data Interchange (EDI) help desk numbers, especially during the hours of 9:00 a.m. to 4:00 p.m. local MAC time, during these testing weeks. The testing weeks will occur in November 2014, March 2015, and June 2015. For more information about acknowledgement testing, refer to the information on your MAC’s website.

End-to-End Testing

During 2015, CMS plans to offer three separate end-to-end testing opportunities. Each opportunity will be open to a limited number of providers that volunteer for this testing. As planned, approximately 2,550 volunteer submitters will have the opportunity to participate over the course of the three testing periods. End-to-end testing includes the submission of test claims to Medicare with ICD-10 codes and the provider’s receipt of a Remittance Advice (RA) that explains the adjudication of the claims. The goal of this testing is to demonstrate that:

• Providers or submitters are able to successfully submit claims containing ICD-10 codes to the Medicare FFS claims systems;
• CMS software changes made to support ICD-10 result in appropriately adjudicated claims (based on the pricing data used for testing purposes); and
• Accurate RAs are produced.

The sample will be selected from providers, suppliers, and other submitters who volunteer to participate. Information about the volunteer registration will be available shortly. Volunteer submitters will be selected nationwide to participate in the end-to-end testing. The sample group of participants will be selected to represent a broad cross-section of provider types, claims types, and submitter types.

Additional details about end-to-end testing will be available soon.

Claim Submission Alternatives

If you are not be able to complete the necessary systems changes to submit claims with ICD-10 codes by October 1, 2015, you should investigate downloading the free billing software that CMS offers via their MAC websites. The software has been updated to support ICD-10 codes and requires an internet connection. This billing software only works for submitting FFS claims to Medicare. It is intended to provide submitters with an ICD-10 compliant claims submission format; it does not provide coding assistance. Alternatively, all MACs offer provider internet portals, and a subset of these MAC portals offer claims submission; providers submitting to this subset of MACs may choose to use the portal for submission of ICD-10 compliant claims. Register in the portals that offer claims submission to ensure that you have the flexibility to submit professional claims this way as a contingency. More information may be found on your MAC’s website.

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