The US Department of Health and Human Services (HHS) issued a rule (CMS-0443-F) finalizing the date of October 1, 2015 as the compliance date for all HIPAA-covered entities to transition from ICD-9 to ICD-10. This transition will have a significant impact throughout the healthcare community for providers and health plans.
Revision 9 of the International Classification of Diseases (ICD-9) has been in use in the United States since the 1970s and contains outdated terms that are inconsistent with today's medical practice, technology and preventive services. With the use of ICD-10, clinicians will be able to capture more detailed information about a patient's health than they could with ICD-9 codes. Improved diagnosis of chronic illness and identification of underlying causes, complications of disease, and conditions that contribute to the complexity of a disease will be some of the benefits of moving to ICD-10. Moreover, ICD-10 will be able to capture the severity and stage of diseases such as chronic kidney disease, diabetes, and asthma.
With a more detailed patient history under ICD-10 coding, providers will have the information needed to better coordinate patient care and over time, ICD-10 coding will improve the level of quality measurement and reporting. The new coding system will facilitate detection of fraud, waste, and abuse that will lead to more accurate reimbursement.
Santa Clara Family Health Plan (SCFHP) has provided a number of resources below, including Frequently Asked Questions, to assist providers with this transition. Additional updates will be posted to this site as they are available. If you have questions about ICD-10 implementation or would like more information, contact the SCFHP Provider Services Department at 1-408-874-1788 or firstname.lastname@example.org.
Prior Authorization Requests
ICD-10 Coding Guidelines for Prior Authorizations
Starting September 1, 2015, Santa Clara Family Health Plan will begin accepting and processing prior authorization requests containing ICD-10 codes for services scheduled on or after October 1, 2015.
- ICD-9 codes will continue to be used for prior authorization of services scheduled through September 30, 2015.
- Some prior authorizations may span the October 1, 2015 compliance date. The ICD code set of the prior authorization will vary, depending on the scenario (refer to the ICD-10 Quick Reference Guide).
- Existing approved prior authorizations coded in ICD-9 whose effective period spans the ICD-10 date of October 1, 2015 do not need to obtain another authorization that is coded in ICD-10. However, claims submitted must adhere to the ICD coding appropriate for Date of Service or Date of Discharge.
- Authorization requests received after the October 1, 2015 transition date that contain ICD-9 will be denied.
EDI Claim Submission
ICD-10 Claims Processing for HIPAA Standard Claim Transactions
Santa Clara Family Health Plan will not accept ICD-9 codes for claims with dates of service (DOS) or dates of discharge (DOD) after the October 1, 2015 compliance date. ICD-9 coded claims processing will not change due to the transition to ICD-10, but rather will be processed based on the date of service/dates of discharge. Systems and processes are being remediated to accommodate ICD-10 for DOS after the compliance date, and will have no impact on the current processing of ICD-9 claims for DOS prior to the compliance date.
While we are pursuing a dual processing strategy (i.e. our systems will be able to process both ICD-9 and ICD-10 claims at the same time), the following key points below should be noted:
- Consistent with CMS guidelines, Santa Clara Family Health Plan will not accept "mixed" claims (claims filed with ICD-9 and ICD-10 codes on the same claim).
- Santa Clara Family Health Plan will not accept ICD-10 codes for dates of service (DOS) or dates of discharge (DOD) prior to the compliance date.
- HIPAA does not allow the use of ICD-9 codes for claims with DOS or DOD after the compliance date.
- When resubmitting claims, providers should utilize the code set that is valid for the DOS/DOD. Santa Clara Family Health Plan will build functionality to dual process (process ICD-10 and ICD-9 natively in our systems) and will leverage that functionality as appropriate to the mandate.
Paper Claim Submission
CMS 1500 Claim Form version 08/05 for paper claims no longer accepted effective October 1, 2015
Effective October 1, 2015: Santa Clara Family Health Plan will only accept paper claims on the updated CMS 1500 Claim Form version 02/12.
- Santa Clara Family Health Plan will no longer accept previous versions of the CMS 1500 claim form for paper claims, including CMS 1500 Claim Form version 08/05.
- This applies to claims that may have been generated prior to the October 1, 2015 effective date, but have not been received by Santa Clara Family Health Plan by the October 1, 2015 transition date.
- Important notes regarding ICD-10 codes can only be filed on the 02/12 version of the CMS 1500 claim form.
- ICD-9 codes can also be filed on the 02/12 version of the CMS 1500 claim form. Santa Clara Family Health Plan began accepting the updated CMS 1500 Claim Form in January 2014.
- We suggest that you transition to using the updated CMS 1500 Claim Form version 02/12 now.
- For information on how to complete the CMS 1500 Claim Form version 02/12, follow the guidelines set forth by the National Uniform Claim Committee (NUCC).
- Please visit the NUCC website at nucc.org which provides helpful resources such as a list of changes between the 08/05 and 02/12 claim form versions and the 1500 Instruction Manual.
ICD-10 Mapping Tool
Santa Clara Family Health Plan offers ICD-10 Mapping Tool to Providers
In an effort to assist providers with the transition to ICD-10, Santa Clara Family Health Plan, offers iSearch, a web based search/look up application.
iSearch functions include:
- Lookup by code or procedure
- Find ICD-10 code using partial text search
- Identify ICD-10 code mapping using ICD-9 codes
- Identify ICD-9 code mapping using ICD-10 codes
iSearch is free of charge to Santa Clara Family Health Plan providers.
- Provider must have a login to use the tool
- Contact Santa Clara Family Health Plan to get your iSearch login at 1-408-874-1788