Apex is Helping Our Providers Focus on
Healing through the ICD-10 Transition

Apex recognizes that the move to ICD-10 is a significant burden on healthcare providers and their staff. With all the moving parts between providers, clearinghouses and payers, it is critical that the transition to ICD-10 happen on time and efficiently. The Apex team will support our clients through all phases of this critical change — from preparation and testing until payment for ICD-10 claims is received. We have updated our systems to transmit ICD-10 codes and will help you make a smooth transition by:

  • Testing your ICD-10 coded claim files (request a test by emailing us)
  • Working with payers and other trading partners to test ICD-10 claim files with them to the extent allowed by the payer
  • Offering helpful educational resources
  • Making sure our team is educated and trained to provide support and answer testing questions for clients, channel partners and payers (email your ICD-10 question)
  • Continuing to accept claims submitted in legacy formats such as 4010, NSF, etc. (Please contact your Apex Account Managers to test these formats)

General FAQ

What is ICD-10?

What is ICD-10?

“ICD-10” is the abbreviated way to refer to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS).

Explain the difference between ICD-10-CM and ICD-10-PCS.

Explain the difference between ICD-10-CM and ICD-10-PCS.

ICD-10-CM is the diagnosis code set that will be replacing ICD-9-CM Volumes 1 and 2. ICD-10-CM will be used to report diagnoses in all clinical settings. ICD-10-PCS is the procedure code set that will be replacing ICD-9-CM Volume 3. ICD-10-PCS will be used to report hospital inpatient procedures only.

Will ICD-10-PCS replace CPT®?

Will ICD-10-PCS replace CPT®?

No. ICD-10-PCS will be used to report hospital inpatient procedures only. The Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) will continue to be used to report services and procedures in outpatient and office settings.

Do I have to upgrade to ICD-10?

Do I have to upgrade to ICD-10?

Yes. The conversion to ICD-10 is a HIPAA code set requirement. Providers, including physicians, are HIPAA “covered entities”, which means that you must comply with the HIPAA requirements.

Who else has to upgrade to ICD-10?

Who else has to upgrade to ICD-10?

Health care clearinghouses and payers are also HIPAA covered entities, so they are required to convert to ICD-10 as well.

Are payers ready for ICD-10?

Are payers ready for ICD-10?

There are hundreds of payers in the United States. So many that we cannot know the status of every one. Apex has successfully tested ICD-10 claims with Medicare, Blue Cross Blue Shield, Medicaid, Worker’s Comp, and other payers. Apex has also participated in various ICD-10 webinars and training sessions with industry leaders – payers, providers, billing services, etc. The general consensus is that the great majority if not all payers are ready for ICD-10. Some payers will be taking steps such as down converting ICD-10 codes to ICD-9, but they will be accepting ICD-10 codes.

Based on industry recommendations as of 10/1/15 Apex will only submit ICD-10 claims to all payers. Keep in mind that Apex will not convert ICD-9 codes to ICD-10 codes or vice-versa. Apex has taken steps to allow ICD-9 claims to pass through from provider to payer after 10/1/15 if a payer specifies that ICD-9 codes must be used.

How will Apex validate ICD-10 and ICD-9 codes starting on October 1, 2015?

How will Apex validate ICD-10 and ICD-9 codes starting on October 1, 2015?

ICD-10 codes go into effect on 10/1/15 for claims with a date of service on or after 10/1/15. Claims with date of service before 10/1/15 will still be required to be billed with ICD-9 codes. Apex will begin sending only ICD-10 claims to all payers starting 10/1/15 for dates of service on or after 10/1/15. Apex will not convert ICD-9 codes to ICD-10 codes or vice-versa. If an ICD-9 code is on a claim with a date of service on or after 10/1/15 the claim will be rejected for invalid diagnosis code by Apex. Claims with a date of service before 10/1/15 will be rejected if it contains an ICD-10 code for invalid diagnosis code. If a payer indicates that they are not ICD-10 ready, then ICD-9 codes will be allowed to process for that specific payer regardless of the date of service on the claim. As always, Apex clients will be able to utilize Apex tools to correct diagnosis codes online.

What if I don’t use the HIPAA electronic transactions?

I thought HIPAA code set standards only applied to the HIPAA electronic transactions. What if I don’t use the HIPAA electronic transactions?

It is correct that HIPAA code set requirements apply only to the HIPAA electronic transactions. But, it would be much too burdensome on the industry to use ICD-10 in electronic transactions and ICD-9 in manual transactions. Payers are expected to require ICD-10 codes be used in other transactions, such as on paper, through a dedicated fax machine, or via the phone.

Why is ICD-9 being replaced?

Why is ICD-9 being replaced?

The ICD-9 code set is over 30 years old and has become outdated. It is no longer considered usable for today’s treatment, reporting, and payment processes. It does not reflect advances in medical technology and knowledge. In addition, the format limits the ability to expand the code set and add new codes.

The ICD-10 code set reflects advances in medicine and uses current medical terminology. The code format is expanded, which means that it has the ability to include greater detail within the code. The greater detail means that the code can provide more specific information about the diagnosis. The ICD-10 code set is also more flexible for expansion and including new technologies and diagnoses. The change, however, is expected to be disruptive for physicians during the transition and you are urged to begin preparing now.

When do I have to convert to ICD-10?

When do I have to convert to ICD-10?

All services and discharges on or after the compliance date must be coded using the ICD-10 code set. The compliance date is October 1, 2015. The necessary system and workflow changes need to be in place by the compliance date in order for you to send and receive the ICD-10 codes.

Will the ICD-10 compliance date be extended again?

Will the ICD-10 compliance date be extended again?

It is very unlikely that the October 1, 2015 compliance deadline will be extended again. You should expect and plan on being ICD-10 compliant by October 1, 2015.

What if I’m not ready by the compliance deadline?

What if I’m not ready by the compliance deadline?

Any ICD-9 codes used in transactions for services or discharges on or after the compliance date will be rejected as non-compliant and the transactions will not be processed. You will have disruptions in your transactions being processed and receipt of your payments. Physicians are urged to set up a line of credit to mitigate any cash flow interruptions that may occur.

What do I need to do now to prepare for the conversion to ICD-10?

What do I need to do now to prepare for the conversion to ICD-10?

There are several steps you need to take to prepare for the conversion to ICD-10.

  • Begin by talking to your practice management or software vendor. Ask if the necessary software updates will be installed to support the ICD-10-CM code set. Determine when they will have your software updates available and when they will be installed in your system. Your conversion to ICD-10 will be heavily dependent on when your vendor has the upgrades completed and when they can be installed in your system. Notify an Apex Account Manager when your updates will be installed.
  • Talk to your payers to determine when they will have their ICD-10 upgrades completed. Apex is actively testing ICD-10 claims with payers, including Medicare, to ensure accurate claim delivery with ICD-10 codes. Due to the very large number of payers in the industry, Apex will not be able to test with all payers, but will ensure that claims sent to all payers will be ICD-10 compliant.
  • Identify the changes that you need to make in your practice to convert to the ICD-10 code set. For example, your diagnosis coding tools, “super bills”, public health reporting tools, etc.
  • Identify staff training needs and complete the necessary training.
  • Conduct internal testing to make sure you can generate transactions you send with the ICD-10 codes.
  • Conduct external testing with Apex to make sure you can send and receive transactions with the ICD-10 codes.

Industry Authority Resources

These links offer valuable insights and tools for transitioning to ICD-10. Apex encourages the use of these resources to accurately assess the needs of your practice in transitioning to ICD-10.