Close

Member Secure Log In

Please sign in using the form below
Close

Provider Secure Log In

Please sign in using the form below

Effective October 1, 2015, CMS implemented ICD-10-CM (diagnoses) and ICD-10-PCS (inpatient procedures), replacing the ICD-9-CM diagnosis and procedure code sets. As a provider, vendor, biller, or administrator, you will need to submit claims appropriately in order to avoid denials.

To learn more, select a question below.

What has changed with ICD-10?
ICD-10 makes use of 3-7 digits, up from the 3-5 digits used with ICD-9. As a result, ICD-10 allows for more detail and specificity in diagnosis and classification. These codes are used to identify symptoms and conditions, shorten patient chart information, note complaints and social circumstances, and more.
How Are Claims Affected?

All claims submitted with dates of service (DOS) after October 1, 2015 must use ICD-10 codes. Combinations of ICD code versions must not be submitted together on a claim. Providers are expected to use the appropriate ICD qualifier (Diagnosis Type Code within the ASC X12 v5010 standard), which Healthfirst uses to distinguish between ICD-9 and ICD-10 code submissions. This means that if the qualifier indicates ICD-9, then the code must be a valid ICD-9 code; if the qualifier indicates ICD-10, then the code must be a valid ICD-10 code. Mixing the qualifiers and diagnosis codes will result in your claim being denied.

These guidelines are very important, as any claims submitted without the appropriate code versions will be denied.

What qualifier should be used for ICD-10 diagnosis codes on electronic claims?

For X12 837P 5010A1 claims, the HI01-1 field for the Code List Qualifier Code must contain the code “ABK” to indicate the principal ICD-10 diagnosis code being sent. When sending more than one diagnosis code, use the qualifier code “ABF” for the Code List Qualifier Code to indicate up to 11 additional ICD-10 diagnosis codes that are sent.

For X12 837I 5010A1 claims, the HI01-1 field for the Principal Diagnosis Code List Qualifier Code must contain the code “ABK” to indicate the principal ICD-10 diagnosis code being sent. When sending more than one diagnosis code, use the qualifier code “ABF” for each Other Diagnosis Code to indicate up to 24 additional ICD-10 diagnosis codes that are sent.

For NCPDP D.0 claims, in the 492.WE field for the Diagnosis Code Qualifier, use the code “02” to indicate an ICD-10 diagnosis code is being sent.

How can I avoid denials?

Code Correctly – All claims submitted with dates of service (DOS) after October 1, 2015 must only include ICD-10 codes.

Don’t Combine Code Versions – Combinations of ICD code versions (ICD-9 and ICD-10) must not be submitted together on a claim.

Use the correct ICD-10 Qualifier Code – Claims with ICD-10 diagnosis codes must use ICD-10 qualifiers. More information on qualifier codes for ICD-10 can be found here.

How should claims that span the ICD-10 implementation date be billed?
CMS has guidance for providers:
What happens if a claim does not have an ICD-10 code?
If a claim does not include a compliant ICD-10 diagnosis for dates of service beginning October 1, 2015, the claim will be denied, with an explanation code stating “CLAIM DENIED: ICD- 9 AFTER TRANSITION – ICD-10 REQUIRED.” It is critical that all provider types include compliant and appropriate diagnosis codes on all claims forms (paper and electronic) as of October 1, 2015.
What happens if a claim is billed with an ICD-10 code for a date of service before October 1, 2015?
The claim will be denied, with an explanation code stating “CLAIM DENIED: ICD-10 BEFORE TRANSITION – ICD-9 REQUIRED.” A corrected claim will need to be submitted for reprocessing. Claims for dates of services provided before October 1, 2015, must be billed with a compliant ICD-9 diagnosis.
How is ICD-10 related to DSM tools for coding that Mental Health Providers use?

The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) was released in May 2013 and took effect on January 1, 2014. As was the case with DSM-IV, the codes within DSM-V contain valid ICD-9 Clinical Modification (CM) codes that can be used to bill dates of service prior to September 30, 2015.

Effective October 1, 2015, the ICD-10-CM codes are the official system that must be used. ICD-10-CM codes are already included in the DSM-V and are listed in parentheses next to each disorder title. Simply use the codes listed in parentheses to code your diagnoses on health insurance claims for services rendered on and after the implementation date of October 1, 2015.

Does the ICD-10 conversion have an effect on provider reimbursement and contracting?
The ICD-10 conversion is not intended to transform payment or reimbursement. However, it may result in reimbursement methodologies that more accurately reflect patient status and care.
What can providers do to ensure compliance with ICD-10?
The ICD-10 conversion affects nearly all provider systems and many processes. The largest impacts will likely be on clinical and financial documentation, billing, and coding. It is important that providers ensure that their billing or software vendors are billing appropriately.
Is Healthfirst using a crosswalk for claims processing?
No, we will not use a crosswalk for claims processing. Standard transactions with dates of service as of October 1, 2015 must be submitted with ICD-10 codes. After that date, we will process claims submitted with ICD-9 codes only for dates of service (outpatient) or dates of discharge (inpatient) prior to October 1, 2015.
Where Can I Find More Information?
We want to make sure you have everything you need to successfully implement ICD-10. To start:

ICD-10 Code Converter Tool

This tool is based on the General Equivalency Mapping (GEM) files published by CMS, and is not intended to be used as an ICD-10 conversion, ICD-10 mapping, or ICD-9 to ICD-10 crosswalk tool. Keep in mind that while many codes in ICD-9-CM map directly to codes in ICD-10, in some cases, a clinical analysis may be required to determine which code or codes should be selected for your mapping. Always review mapping results before applying them.

Other ICD-10 Resources
CMS ICD-10 Resources
The ICD-10 Transition: An Introduction
Institutional Services Split Claims Billing Instructions for Medicare Fee-For-Service (FFS) Claims
ICD-10 Resources for Providers
ICD-10 Resources for Vendors
The ICD-10 Transition: Focus on Non-Covered Entities
Road to 10: The Small Physician Practice’s Route to ICD-10
Medicaid Managed
Care and Child Health Plus

1-866-463-6743
Monday - Friday, 8am to 6pm
The Essential Plan
and Leaf Plans

1-888-250-2220
Monday - Friday, 8am to 8pm
FIDA Participant Services
1-855-675-7630

TTY English
711
Monday - Sunday, 8am to 8pm
Broker Services:
1-855-456-3668
Monday - Friday, 9am to 5pm
Employer Services
1-855-949-3668
Monday - Friday, 9am to 5pm
Total Plan and Pro Plan Members
1-855-789-3668
TTY English: 1-855-779-1033
Monday - Friday, 8am to 6pm
Senior Health Partners
1-866-585-9280

TTY English
Monday - Friday, 8am to 8pm
Saturday, 10am to 6:30pm

TDD/TTY English
1-888-542-3821
TDD/TTY Español
1-888-867-4132
Current Medicare
Plan Members

1-888-260-1010
Monday - Sunday, 8am to 8pm

Become a Medicare
Plan Member

1-877-237-1303
Monday - Sunday, 8am to 8pm

TDD/TTY English
1-888-542-3821
TDD/TTY Español
1-888-867-4132
Personal Wellness Plan
1-855-659-5971
TTY
1-888-542-3821
7 days a week, 24 hours a day
We can call you