ICD-10 Overview

Louisiana Healthcare Connections successfully transitioned to ICD-10 on 10/1/2015 as mandated by CMS. Providers must submit claims in accordance with CMS and state guidelines:

Claims Processing

The following information applies to paper, web, and standard electronic (837 X12) claims.

  • Claims may not contain a combination of ICD-9 and ICD-10 codes. 
  • Claims must be submitted with ICD-10 codes if the date of discharge / date of service is on or after the ICD-10 compliance date of 10/1/2015.
  • Claims must not be submitted with ICD-10 codes if the date of discharge / date of service is prior to the compliance date of 10/1/2015.
  • For some claims which span the ICD-10 compliance date, the admit date on the claim can be prior to the ICD-10 compliance date and the claim can still contain ICD-10 codes. For other claims which span the ICD-10 compliance date, a splitting of the claim into two separate claims is necessary. CMS has outlined guidance on which claims will need to be split in this claims processing document (SE1408).
  • CMS uses the “bill type” on an institutional claim for determining whether a claim that spans the compliance date should be split. In general, inpatient claims can have dates of service which span the compliance date and contain ICD-10 codes. Outpatient and professional claims cannot have dates of service which span the compliance date and have ICD-10 codes. For outpatient and professional claims, providers must split claims into two separate claims (one claim with a end date on 9/30/15 and another claim with a start date of 10/1/15).
  • Interim bills for long hospital stays (TOB: 112, 113, 114) are expected to follow the same rules as other claims. If a provider submits a replacement claim (TOB: 117) to cover all interim stays, it is expected that the provider must re-code all diagnoses / procedures to ICD-10 since the replacement claim will have a discharge / through date post-compliance.
  • All first-time claims and adjustments for pre-10/1/2015 service dates must include ICD-9 codes, even if claims are submitted post-10/1/2015. Claims with pre-10/1/2015 service dates can be submitted with ICD-9 codes for as long as contracts and provider manuals specify.
  • Reiteration: Claim submission date does not determine whether ICD-9/10 codes should be used. All ICD-9/10 claims submission rules outlined by CMS are based on patient discharge date, or date of service for outpatient/professional services.

Claims are reimbursed according to state reimbursement guidelines. Claims are adjudicated natively in ICD-9 for dates of service prior to 10/1/15 and natively in ICD-10 for dates of service on and after 10/1/2015, consistent with CMS requirements.

Authorization Processing

ICD-10 diagnosis codes are accepted on prior authorization requests for services with a start date on or after the ICD-10 compliance date of 10/1/15. ICD-9 codes will no longer be accepted on prior authorization requests submitted on the ICD-10 compliance date or later except in the case of retro authorizations for services with a start date on or before 9/30/15. ICD-9 procedure codes are not used on authorizations and ICD-10 procedure codes will not be used on authorizations.

Questions

Providers: For additional questions, please contact Provider Services at 1-866-595-8133.

Clearinghouses: For additional questions, please contact the EDI service desk at 1-800-225-2573, ext. 25525 or EDIBA@centene.com.

ICD-10 Implementation and Testing Approach

Our ICD-10 implementation approach aligns with CMS guidance and recommended timeframes.

Transactional-Level Testing

An ICD-10 assessment was completed in 2011-2012 and HIPAA compliance testing with providers, clearinghouses, vendors and state agencies began on July 2013. Transactional-level testing is available today to any provider interested in participating and will continue to be available through the ICD-10 compliance date. As part of this testing effort, providers who register in Ramp Manager (application used for all testing efforts) and submit 837 X12 test claims will receive TA1, 999, 277CA, and 271 eligibility responses.

Providers or clearinghouses who are interested in transactional-level testing can contact the EDI service desk at 1-800-225-2573, ext. 25525 or EDIBA@centene.com for further instructions. Providers or clearinghouses who are interested in testing must be direct electronic claim submitters (837 X12 claims).

End-to-End Testing

End-to-end testing will broaden the focus of transactional-level testing and will encompass the return of remittance advices (RAs) / explanation of payments (EOPs). Providers who conduct end-to-end testing will receive the outputs from transactional-level testing in addition to an 835 X12 Remittance Advice file.

Providers or clearinghouses who are interested in conducting end-to-end testing should reach out to the health plan for further details. If contacts within the health plan are unavailable, interested providers can contact ICD10ProviderTesting@Centene.com.

End-to-end testing will only be conducted with a limited number of providers and will occur in Q1-Q2 2015. Providers and clearinghouses who are confirmed as test partners will be permitted to submit up to 50 ICD-10 coded test claims in an electronic 837 X12 format. The Ramp Manager application (application used for all testing efforts) will be used as a mechanism for receiving electronic test claims and distributing electronic remittance advices. Providers who normally submit claims via clearinghouses will be asked to work with their clearinghouse on test claim submissions.