These FAQs regarding ICD-10 were
compiled based on questions received by OHCA and other state Medicaid agencies.
If additional questions arise that would benefit the provider community as a
whole, they will likewise be posted with the appropriate response.
What is OHCA’s position?
- On April 1, 2014, President Obama signed Congressional
Bill HR 4302 into law which delays the implementation of ICD-10 by at
least one year from October 1, 2014, to at least October 1, 2015.
- On July 31, 2014, the Department of Health and Human
Services (HHS) posted the final rule that formally set the compliance date
for ICD-10 to October 1, 2015.
- As a result of the delay, OHCA will continue to accept
only ICD-9 codes and deny any ICD-10 codes submitted on a claim until the compliance
date now set for October 1, 2015.
What are some of the benefits?
- Updated medical terminology and classification of
diseases to be consistent with current clinical practice.
- Improved efficiencies and lowered administrative costs.
- Possible reduction in requests for additional
documentation to support claims.
- Better support of medical necessity of services
Who is affected by the transition to
Everyone in health care from patient
to payer will be affected by the transition to ICD-10, either directly or
What is the difference between ICD-9
- There are approximately 69,000 ICD-10 diagnosis
codes versus approximately 14,000 ICD-9 diagnosis codes.
- There are approximately 72,000 ICD-10 procedure
codes versus approximately 4,000 ICD-9 procedure codes.
- Due to the added complexity and specificity on the
ICD-10 codes, some ICD-9 codes do not map to any ICD-10 codes and some
ICD-10 codes do not map to any ICD-9 codes.
What happens if I submit ICD-10
codes on a claim prior to the federally mandated implementation date?
- Any ICD-10 codes submitted on a claim prior to the
federally mandated implementation date will be denied as an invalid code.
Only ICD-9 codes will be accepted until the federally mandated
What happens if I don’t migrate to
ICD-10 by the compliance date?
- OHCA will not accept ICD-9 codes with dates of service
on or after the federally mandated compliance date, currently set for
10/01/2015. Claims submitted after that date, but with dates of service
prior to that date, must contain the applicable ICD-9 codes.
- The processing of claims with dates of service that
span the mandated implementation date for ICD-10 codes, will be as follows:
type: Institutional (e.g., UB04) Processing: Based on Date of Discharge
Discharge date before 10/01/2015
submit ICD-9 codes only
Discharge date on or after
10/01/2015 submit with ICD-10 codes only, regardless of the first date of
DO NOT split claims into multiple
based on dates of service.
type: Non–Institutional (e.g. 1500) Processing: Based on FDOS of the Claim
FDOS before 10/01/2015 use ICD-9
FDOS on or after 10/01/2015 use
ICD-10 codes only
Pharmacy claims will use dispense
date as the FDOS
MUST split claims that span ICD Code
set dates into multiple claims as defined below.
Claims Submission and Processing:
non-institutional claims only, if service dates on a submitted claim are within
both the ICD-9 and ICD-10 effective date ranges, the claim will be denied with
a new system edit.
cases, the claim should be split: one submitted with services within the ICD-9
date span containing ICD-9 codes only, and the other with services within the
ICD-10 date span containing ICD-10 codes only.
How will OHCA communicate to
- OHCA plans to communicate with affected parties
primarily via the provider home page at www.okhca.org , the SoonerCare Provider
Portal (secure site), banner messages, EDI emails and remittance advice (RA)
messages. In some instances, OHCA may contact providers directly.
- Additional training for ICD-10 in the form of workshops
and webinars have been and will continue to be provided prior to the
implementation date. See the Training section on the Provider home page at www.okhca.org for more details.
What is OHCA’s status with preparing
for the transitions?
- OHCA engaged each of its business areas and conducted
an agencywide ICD-10 impact analysis of business processes, policies and
- Results of that impact assessment were used to develop
a long-term roadmap identifying what, how and when the required changes
will be completed.
- All documents located on the Provide Portal impacted by
ICD-10 have been identified and are in the process of being updated
- OHCA has completed making necessary system changes and
has conducted thorough internal testing of those changes to validate
claims are processed appropriately.
What is OHCA’s approach for
transitioning between the ICD-9 and ICD-10 code sets?
- OHCA has purchased the 3M™ Code Translation Tool (CTT)
to assist with the translation between ICD-9 and ICD-10. The tool is based
on the General Equivalency Mappings (GEMS) which were developed by 3M™
under contract for CMS, and they are fully integrated into the tool. It
will automate many of the translations between ICD-9 and ICD-10 and
identify the translations that require manual intervention and decision
making from subject matter experts.
Will there be testing between OHCA
- OHCA recently completed an initial beta round of
external provider testing on August 29, 2014. Currently, three additional
rounds of testing are tentatively scheduled as follows:
- Round 1: November 3, 2014 - December 26, 2014
- Round 2: February 2, 2015 – April 30, 2015
- Round 3: June 1, 2015 – August 28, 2015
- OHCA is currently reaching out to specific billing
agents and clearinghouses to define which providers will be selected to participate
in the next rounds of testing. Each billing agent or clearinghouse will be
allowed to select no more than two of the providers for which they submit
claims for in production today.
- It’s recommended that providers contact their billing
agent or clearinghouse ASAP to let them know whether you’re interested in
participating in testing and to see if they’re capable and willing to
submit your test claims, if they’re contacted by HP to participate in the
testing. You will only be selected for testing if OHCA selects your
billing agent or clearinghouse and they, in turn, select you as one of the
two providers they’re allotted (as noted in the second bullet above).
- For providers who would like to be considered for
testing but do not use a
billing agent or clearinghouse - If
you are ready to submit test claims and submit your own EDI 837 files, or
enter claims directly via the secure Provider Portal, please send an email
to the ICD-10 email account at: ICD10project@okhca.org indicating your interest in testing. From the emails
received, OHCA will select a defined set of providers to participate in
testing depending upon the number of requests. In your email request to
test with OHCA, please include all pertinent contact information and which round of testing in which you would like to participate. Such contact
information would include:
- SoonerCare provider number and location (e.g.
- Name of organization
- Name, email and phone number of the person responsible
for ICD-10 testing
Will the migration to ICD-10 effect
- The impacts on reimbursement are being evaluated for
moving from 17,000 to 168,000 codes. It’s possible that with the
specificity inherent in the ICD-10 code set, reimbursements may be more
directly related to the complexity of treating a member’s condition.
However, overall reimbursements must remain budget neutral as required by state
What can I do to get prepared
regarding education and training?
- Get everyone in the practice involved in the
implementation project early.
- Assess educational needs.
- Identify those who will need education and training.
- Identify the type and level of education and training
- Have physician practice coders learn ICD-10-CM, not
ICD-10-PCS (which is all they will need).
- Focus on subset of codes used by practice in training
physician practice coders who work in a medical specialty area .
- Determine how education will be delivered.
- Inform all staff as to the reasons for moving to
ICD-10-CM, the time frame necessary for implementation and how ICD-10-CM
impacts the practice.
- Develop materials to disseminate to managers and staff
regarding the timeline and status of implementation. Communication might
include staff meetings, newsletters, emails or other methods of
- Develop a schedule for when the information will be
communicated. Staff members need to understand not just what is happening
but what they need to do and how it will impact their work. By
communicating this information during the early phase of implementation,
managers can make staff members aware of their responsibilities and roles
in the implementation process.
- Training schedules and training plans should be
communicated to staff early to avoid causing them anxiety about learning
- Conduct periodic briefings for staff to keep the entire
practice updated on the progress of the project.
What considerations are there for
- Planning and preparation should already be underway or
started very soon.
- Providers should contact their billing or software
vendor to understand their plans for conversion and testing.
- Testing is going to be significant, so identify
functionality that needs to be tested and verified; assign specific people
to test various elements; and know where your software vendors,
clearinghouse or billing agent stand in their own testing readiness.
Resources and Information
- Centers for Medicare & Medicaid Services (CMS):
- Workgroup for Electronic Data Interchange (WEDI):
- World Health Organization (WHO):
- Health Information and Management Systems Society
For additional questions and direct
inquiries regarding ICD-10, please email them to the ICD-10 team at ICD10Project@okhca.org.