ICD-10 Arrives Early – April 1, 2014: CMS Announces New CMS-1500 Healthcare Claim Form

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ICD-10 Arrives Early – April 1, 2014: CMS Announces New CMS-1500 Healthcare Claim Form

The U.S. Health and Human Services (HHS) Centers for Medicare and Medicaid (CMS) announced today that Medicare will begin accepting a revised CMS-1500 form (version 02/12)  on January 6, 2014.  Embedded in this is a requirement for some healthcare IT vendors to start supporting a component of the International Classification of Diseases version 10 (ICD-10) earlier than the anticipated October 1, 2014 date.

According to CMS, Starting April 1, 2014, Medicare will accept only the revised version of the form.

The revised form will give  HIPAA Covered Entities who are health care providers the ability to indicate whether they are using ICD-9 or ICD-10 diagnosis codes, which is important as the October 1, 2014, transition approaches.  The revised form also allows for additional diagnosis codes, expanding from 4 possible codes to 12.

Effectively this means that any healthcare IT system that adjudicates, submits, or reports on claims data, where this requirement applies, that was scheduled to be compliant as of October 1, 2014 with ICD-10 must actually comply with a component of the ICD-10 requirements related to claims data as early as of April 1, 2014.

Only providers who qualify for exemptions from electronic submission may submit the CMS-1500 Claim Form to Medicare.  Exempted providers include those submitting dental claims, small providers with less than 10 FTEs, non-U.S. providers, and others.   For those providers who use service vendors, CMS encourages them to check with their service vendors to determine when they will switch to the new form.  While this might sound like only a small subset of the healthcare industry is impacted, remember that these “forms” get converted back to data.  The data types, fields and supporting business rules and workflows will be impacted. Since most adjudication systems, reporting and related supporting systems are not ‘versioned’ for exempted providers, this change effectively impacts a large component of health IT vendors and those who manage internally built systems to support CMS standards.

ICD-10 promises to introduce better information to improve the quality of healthcare by providing more granular data on the condition of the patient, how the patient acquired a condition, how the patient was treated for the condition and why.  This in turn it is hoped, will improve population health management and other components of healthcare.   At the same time ICD-10 is viewed as disruptive because it requires a re-write of healthcare IT systems, processes, and substantial re-training of medical coders, billing personnel, physicians, and other clinical staff.   From a financial perspective ICD-10 introduces a new payment paradigm including opportunities for improved reimbursement and potential risks of decreased reimbursement for HIPAA Covered Entities who do not carefully examine the nuances of the ICD-9 to ICD-10 transition.

ICD-9 codes must be used for services provided before October 1, 2014, while ICD-10 codes should be used for services provided on or after October 1, 2014. ICD-10 CM must be used for all diagnosis for both inpatient and outpatient claims.  ICD-10 PCS must be used for all inpatient procedures.

HIPAA Covered Entities  and Healthcare IT vendors who are building test plans must take this into consideration as they plan for the ICD-10 transition.

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By | 2017-05-04T04:06:41+00:00 September 5th, 2013|CMS, ICD-10|0 Comments

About the Author:

Michael is Managing Partner & CEO of No World Borders, a leading health care management and IT consulting firm. He leads a team that provides Cybersecurity best practices for healthcare clients, ICD-10 Consulting, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, Insurance Fraud, payor-provider disputes, and consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $4 billion in healthcare mergers and acquisitions. Education: UC Irvine – Economics and Computer Science, University of Southern California – Business, Stanford Medical School – Biomedical Informatics, Harvard Law School – Bioethics.

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