Q: Am I required to report external causes of injury?
A: External Cause Codes
Just as with ICD-9-CM, there is no national requirement for mandatory ICD-10-CM external cause code reporting. Unless a provider is subject to a state-based external cause code reporting mandate or these codes are required by a particular payer, reporting of ICD-10-CM codes in Chapter 20, External Causes of Morbidity, is not required. If a provider has not been reporting ICD-9-CM external cause codes, the provider will not be required to report ICD-10-CM codes in Chapter 20, unless a new state or payer-based requirement regarding the reporting of these codes is instituted. Such a requirement would be independent of ICD-10-CM implementation. In the absence of a mandatory reporting requirement, providers are encouraged to voluntarily report external cause codes, as they provide valuable data for injury research and evaluation of injury prevention strategies.
Q: I don't always know the diagnosis until testing has been completed. Will unspecified codes be denied?
A: Sign/Symptom/Unspecified Codes
In both ICD-9-CM and ICD-10-CM, sign/symptom and unspecified codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patients health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter.
If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information isnt known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). In fact, unspecified codes should be reported when they are the codes that most accurately reflects what is known about the patients condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.
Q: How do I report ICD-10 codes on claims when the dates of service span from prior to 10/1/2015 to on or after 10/1/2015?
A: Many payers are requiring claims with dates of service that span the October 1, 2015 implementation date to be split so that the services prior to 10/1/2015 are billed separately and utilize ICD-9 codes; services on and after 10/1/2015 are billed separately and utilize ICD-10 codes.
Check specific payer guidelines for processing claims for services that span the 10/1/2015 ICD-10 transition date.
Q: If I submit or process a transaction with an ICD-9 code for a date of service after October 1, 2015, am I HIPAA compliant?
A: The date of service determines the compliant code format to be used in a claim regardless of the date the claim is filed or submitted. Physicians will submit claims after October 1, 2015 with ICD-9 codes when the services were performed prior to October 1, 2015. Payers will process claims if received after October 1, 2015 with ICD-9 codes when the services were performed prior to October 1, 2015. This situation is HIPAA compliant.
Q: How long after the October 1, 2015 ICD-10 compliance date must I continue to report and/or process ICD-9 codes?
A: Each payer determines their late filing requirements for standard transactions and ICD-10 does not require a change to these requirements. These deadline requirements vary among plans. Contact your payer for the current information regarding late filing for claims.
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