Revenue Cycle Management Blog | GroupOne Health Source

4 Major Insurance Payers Share Policies on Reimbursing ICD-10 Claims

Written by Kaitlyn Houseman | October 19, 2015

While the Centers for Medicare and Medicaid Services announced a year's grace period this summer when it comes to claims coded with ICD-10, not all large commercial payers are following suit.

According to the CMS announcement, during the 12 months immediately following the October 1, 2015, date, “Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.”

Susan Morse with Healthcare Payer News recently asked some of the top plans their reimbursement policies and whether they are following CMS guidelines in not denying Medicare Part B physician fee schedule claims that lack specificity, as long as they contain an ICD-10 code from the right family of codes.


"Aetna will require providers to use ICD-10 coding for all transactions with an October 1, 2015 date of service and forward," said spokesman Matt Clyburn. "While Medicare may be making advanced payments available if Part B Medicare contractors aren't able to process claims within established time limits due to administrative issues, we don't plan on taking such action. Based on results from our extensive provider testing, we're confident that this won't be necessary."


"Humana is continuing to follow CMS guidance on the transition," said spokesman Kate Marx, without offering further detail.


"Anthem will adhere to the CMS/AMA Medicare Part B announcement released on July 6, 2015," said spokesman Gene Rodriguez. "Specifically, Anthem will not reject Medicare Part B Fee-For-Service claims that are coded with an ICD-10 within the correct family even if the correct level of specificity was not used."

"The announcement applies to Medicare Part B FFS claims only," Rodriguez said. "All claims, including Medicare Part B, must have a valid ICD-10 code for a date of service on or after Oct. 1, 2015."


"A code will be invalid if it has not been coded to the full number of characters required," said spokesman Mark Slitt. "When sufficient clinical information isn't known or available about a particular health condition to assign a more specific code, it will be acceptable to report the appropriate 'unspecified' code (for example, a diagnosis of pneumonia has been determined, but not the specified type). Cigna is following the CMS claim submission guidelines."

UnitedHealth Group, Kaiser Permanente and Harvard Pilgrim Health Care all declined to share their policies.

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