What does International Classification of Diseases, 10th Revision (ICD-10) compliance mean?
ICD-10 compliance means that all HIPAA-covered entities are able to successfully conduct health care transactions on or after October 1, 2014, using the ICD-10 diagnosis and procedure codes. ICD-9 diagnosis and procedure codes can no longer be used for health care services provided on or after this date.
Why is the ICD-10 transition necessary?
ICD-10 is a provision of HIPAA, as regulated by the U.S. Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS). This federal mandate pertains to all HIPAA-covered entities.
The transition from ICD-9 to ICD-10 is occurring for the following reasons:
- ICD-9 codes have limited data about patient’s medical conditions and hospital inpatient procedures.
- ICD-9 codes use outdated and obsolete terms and are not consistent with current medical practices.
The structure of ICD-9 limits the number of new codes that can be created, and many ICD-9 categories are full. A successful transition to ICD-10 is vital to transforming our nation’s health care system.
Codes change every year, so why is the transition to ICD-10 any different from the annual code changes?
ICD-10 codes are different from ICD-9 codes in several ways. Currently, ICD-9 codes are for the most part numeric and have three to five digits. ICD-10 codes are alphanumeric and contain three to seven characters. ICD-10 codes provide a higher level of description. However, like ICD-9 codes, ICD-10 codes will be updated every year.
Will ICD-10 replace Current Procedural Terminology (CPT) procedure coding?
No. The transition to ICD-10 does not affect CPT coding for outpatient procedures. Like ICD-9 procedure codes, ICD-10 Procedure Coding System (PCS) codes are for hospital inpatient procedures only.
What is the implementation date for ICD-10?
On October 1, 2014, medical coding in U.S. health care settings will change from ICD-9 code sets to ICD-10 code sets.
After the October 1, 2014, implementation date, when do I use ICD-9 versus ICD-10 on my claim?
Please refer to the chart below, using the date specified in the date field, to determine the ICD code version to use. If the value of the date field is before October 1, 2014, use ICD-9 to code the diagnosis. If the value of the date field is on or after October 1, 2014, use ICD-10.
| Claim Type | Claims | Date Field To Be Used For Determining ICD Code Version |
| 1 | Pharmacy | Date of service |
| 2 | Long Term Care (LTC) | Through date |
| 3 | Inpatient | Through date |
| 4 | Outpatient | From date |
| 5 | Medical | From date |
In addition, all claims received on or after the ICD-10 compliance date will require a version indicator (ICD-9 = 9 or ICD-10 = 0).
Will there be a grace period for converting to ICD-10?
How is Medi-Cal addressing the implementation of ICD-10?
Medi-Cal will be using a crosswalk solution in the legacy California Medicaid Management Information System (CA-MMIS). Medi-Cal has mapped all ICD-10 codes to corresponding ICD-9 codes by starting with the General Equivalence Mappings (GEMs) provided by the Centers for Medicare & Medicaid Services (CMS) and modifying the mappings to align with existing Medi-Cal policy. Claims will be run against the crosswalk to determine the ICD-9 value to process through the system.
What is a crosswalk solution?
Medi-Cal has mapped all ICD-10 codes to corresponding ICD-9 codes starting with the General Equivalence Mappings (GEMs) and Reimbursement Mappings provided by the Centers for Medicare & Medicaid Services (CMS) and modifying the mappings to align with existing Medi-Cal policy. Claims that are submitted with ICD-10 starting October 1, 2014, will be run against this crosswalk to identify the appropriate ICD-9 code that will be used to process the claim.
Will an ICD-10 to ICD-9 crosswalk be published?
Medi-Cal will not publish the crosswalk. However, the provider manuals will be updated with the ICD-10 codes as appropriate.
Who is affected by the transition to ICD-10? If I don’t deal with Medicare claims, will I have to transition?
Everyone covered by HIPAA must transition to ICD-10. This includes providers and payers who do not deal with Medicare or Medicaid claims.
What if I don’t make the transition to ICD-10?
For HIPAA-covered entities, transition to ICD-10 is not an option. Claims for all services and hospital inpatient procedures performed on or after the compliance deadline must use ICD-10 diagnosis and inpatient procedure codes. This change does not apply to Current Procedural Terminology (CPT) coding for outpatient procedures. Without ICD-10, providers will experience delayed payments or even non-payments; increased rejected, denied or pending claims; reduced cash flows and ultimately lost revenues.
It is important to note, however, that claims for services and inpatient procedures provided before the compliance date must use ICD-9 codes.
Is Medi-Cal policy going to change with ICD-10?
Medi-Cal will be updating the provider manuals to account for the change to ICD-10 in 2014. However, due to the size of the ICD-10 code set and limitations in the legacy MMIS policy will not change.
Will Medi-Cal accept claims with both ICD-10 and ICD-9 codes on the same claim form?
No. Medi-Cal will accept claim forms containing only ICD-9 or ICD-10 codes.
If I transition early to ICD-10, will Medi-Cal be able to process my claims?
The U.S Department of Health and Human Services (HHS) has mandated that all HIPAA-covered entities will transition to the use of ICD-10 on October 1, 2014, and early or late transitions will not be allowed. Medi-Cal will not be able to process claims using ICD-10 until October 1, 2014.
Are paper claims affected by the transition to ICD-10?
Yes. All claim transactions, whether paper or electronic, except dental claims, will be required to be submitted using ICD-10 codes.
What type of training will providers and staff need for the ICD-10 transition?
Medi-Cal will be providing education about the use of ICD-10 for submitting claims to Medi-Cal. Providers are encouraged to visit the Medi-Cal website regularly throughout the course of the transition to access the latest information about education opportunities.
In addition, ICD-10 resources and training materials may be available through the Centers for Medicare & Medicaid Services (CMS), many professional associations and societies, and software/system vendors.
Where can I get additional information about ICD-10?
More information about ICD-10 is available on the
ICD-10 page of the CMS website.
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