ICD-10 and Impacts to Pre-cert/Authorization Process

This is a second article I wrote for WEDI last year in regards to the pre-cert/auth process.  Since I’m working on a payer implementation of ICD-10, my knowledge is primarily from that perspective.  However, it’s still good information for the provider community to keep in mind.  


ICD-10 and the Impacts to the

Pre-cert/Authorization Process:

What You Need to Know

By Gina Park, Director of Consulting Services, Axiom Systems, Inc.

Those of us who have been reading and hearing about ICD-10 in the healthcare industry know that this is DOS (date of service) or DOD (date of discharge) driven compliance.  “You cannot submit claims using ICD-10 diagnosis or ICD-10 procedure codes if the DOS or DOD is before 10/1/14!!” we’ve been beating into the heads of those in our organizations.  We got it, loud and clear.  However, this doesn’t mean that all HIPAA covered entities impacted by ICD-10 will not start speaking the language of ICD-10 until the magical October 1, 2014 date.

What about pre-certs and authorizations?

Typically, a provider will call a payer for prior approval of a procedure a few weeks in advance.  This will obviously not be the case for emergent admissions to inpatient facilities.  The provider will supply the procedure code (CPT-4/HCPCS) as well as the medical condition of the patient in the form of either a diagnosis description or the actual ICD-9 diagnosis code.  The payer will have their pre-cert/authorization policies based on the procedure being requested in the form of CPT-4/HCPCS code(s) and will not be based off the ICD-9 diagnosis code.  However, certain procedures may require the application of clinical criteria that will utilize the diagnosis in order to derive medical necessity.  In summary, the CPT-4/HCPCS procedure code drives the pre-cert/authorization process and not the diagnosis code.  Yay!

For pre-certs and authorizations whose effective periods will span the 10/1/14 compliance, there’s a general rule of thumb to keep in mind:  the corresponding claims must match the authorization.  This means if the authorization has an ICD-9 diagnosis code attached to it, the corresponding claim should also have an ICD-9 diagnosis code attached to it.  The same follows for ICD-10 diagnosis codes.  CMS Transmittal 950 that lays out clear direction on how to submit both institutional and professional claims if the dates span the 10/1/14 compliance date.  For the most part, institutional claims should use the discharge date in determining whether to file the claim w/ICD-9 or ICD-10 and professional claims should split the claim based on date of service.  A HIPAA standard transaction that includes both authorizations and claims cannot be submitted using both ICD-9 and ICD-10 codes.  Scenarios such as long term care, hospice, DME rentals, or lengthy inpatient confinements that get interim billed should follow the same authorization requirement since the claims have to be split.  In the case of interim bills where there is no discharge date, the claim will be filed using ICD-9 if the statement from and through dates are 9/30/14 and prior and a separate interim bill will be filed using ICD-10 if the statement from and through dates are 10/1/14 and later.  Based on how the payer has their claims to authorization adjudication rules setup, it may not match if the diagnosis code is not exact or is a related diagnosis (first 3 characters of the diagnosis code match).

From a cursory review of ICD-10 payer communications to their provider community, health plans will be ready to start accepting auth requests using ICD-10 around the June/July/August timeframe of 2014.  This should give all segments of the healthcare industry time to plan their internal training and process rollouts around prior approvals for a successful rollout next summer.

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