Preparing for ICD-10: Are You Ready?

By Caitlin Henry September 22, 2015

For the past year, it’s been difficult to overlook the numerous reminders from the Centers for Medicare and Medicaid Services (CMS) regarding the upcoming transition from ICD-9 to ICD-10. The change is required for everyone covered by the Health Insurance Portability Accountability Act (HIPAA) and plays a critical role for our clients in the area of Medicare compliance, particularly Section 111 reporting.

What additional information does ICD-10 provide to Medicare, and how do you ensure that your company is in compliance with reporting requirements? Here’s some vital information you should be aware of:

  • More than 68,000 ICD-10 codes, ranging from three to seven characters, are available to providers. The first three characters of the code identify the category of the diagnosis. For example, G00 through G99 categorize diseases of the nervous system. The next three characters detail the etiology, site, and severity of the injury. The final character explains the episode of care for certain types of conditions, for example, initial or routine visit.
  • The additional details provided through ICD-10 codes reported for Section 111 will enable Medicare to process claims more accurately. The new codes also allow the Benefits Coordination and Recovery Center (BCRC) to search more effectively for Medicare claims history and pursue recovery of benefits for which Medicare was not the primary payer.
  • Effective October 1, 2015, any claim reported with a CMS Date of Incident on or after that date must be reported with an ICD-10 code valid for Section 111 reporting. Any claims reported after October 1 with a CMS Date of Incident before that date may still be reported using an ICD-9 code. This includes not only “Add” records but also “Update” records on previously reported claims accepted by CMS.
  • Regardless of the CMS Date of Incident entered, CMS will not accept claims reported with both ICD-9 and ICD-10 codes.
  • When selecting one or more ICD codes to report, be sure to include only those that describe the injury and/or diagnosis for which Ongoing Responsibility for Medicals (ORM) was assumed or released. This will help with denial of Medicare benefits issues for the injured party.

If you’re currently an MSP Navigator client, rest assured that new logic has been programmed and tested with CMS to ensure a smooth transition. MSP Navigator provides many valuable tools, including ICD Lookup and a Missing Section 111 Data report, to help you report your claims error-free. The ICD Lookup tool is publicly available here.Please feel free to use the link as a resource to ensure selected codes are valid for Section 111 reporting. A complete list of included and excluded diagnosis codes can also be found here under the Reference Materials section.


Caitlin Henry

Caitlin Henry is director of Section 111 operations at ISO Claims Partners. Caitlin specializes in the client implementation and support of MSP Navigator, ISO Claims Partners’ Section 111 (S. 111) reporting solution. Her consultative and collaborative approach to client onboarding results in the most efficient use of MSP Navigator for our clients’ business. Caitlin also manages the Section 111 third-party administrator (TPA) program for one of the country’s largest insurers, monitoring the performance and compliance of more than 60 TPAs. Before joining ISO Claims Partners, Caitlin was a project manager for a data analytics company. She is currently in the process of obtaining her Associate in General Insurance (AINS) certification.