ICD-10 End-to-End Testing Checklist
Institutional Providers
Thank you for volunteering to conduct ICD-10 testing with CGS. Your
partnership puts us on course for successful implementation of this
important initiative by October 1, 2015. Below are testing suggestions
and tips we would like to share with you as you continue to test:
PREPARING FOR TESTING
Testing will be conducted July 20 through July 24, 2015.
Test claim files must be sent to the Medicare Administrative
Contractor (MAC) the same way you send claims today.
Test claim files must use the Submitter ID (Trading Partner ID)
that was provided to the MACs during the volunteer registration.
Test claim files must be marked as Test by using indicator T
in the ISA 15 field.
Test claim volume is limited to a total of 50 claims for the entire
testing week with no more than 3 test files. If more than your
allotted 50 claims are submitted for the week, they may not
be processed.
Remittance Advices (RAs) will be produced daily as claims
complete processing; please be sure to check them daily to
identify any discrepancies that have occurred and contact your
MAC accordingly. Please note: Certain types of claims could take
up to two weeks.
The ERA files will be marked as Test files in the ISA 15 field
with a T.
Be sure the MAC has a complete list of all of the Health Insurance
Claim Numbers (HICNs) that will be used to test. Do not submit
claims with any other HICNs.
Ensure the MAC has a complete list of the NPIs and PTANs that
you will use to test because the MACs must set up their files to
accept them.
If you use NPIs, PTANs, or HICNs that were not submitted to the
MAC on the volunteer form, your claims will not be processed.
CREATING TEST CLAIMS
IMPORTANT: Claims that you would normally submit should be
used to start building your test cases. Include procedure codes you
commonly bill, along with the ICD-10 diagnosis that most closely
represents the diagnosis you would submit for that type of claim.
Refer to the Future Local Coverage Determinations for questions
on the covered diagnosis codes for a particular policy.
Ensure your claim has complete information so it is not rejected
for anything not related to ICD-10. Remember the purpose of your
testing is to help you prepare for ICD-10. The Medicare claims
processing system used to process test claims is the same one
you use today, with the exception of the ICD-10 logic. If your
test claims do not meet all of the existing coding guidelines for
submitting a proper claim, the claim will reject and not show on
your RA. Most test claim errors in the previous end-to-end testing
week were not ICD-10 related.
Originated April 10, 2015 | Updated June 11, 2015
2015 Copyright, CGS Administrators, LLC.
Some general claim criteria are provided below:
1. A discharge status is required on all type of bills.
2. ICD-10 Procedure codes are only billed on inpatient claims.
3. Type of bills 11x, 12x, 18x, 21x, 22x, 32x, 41x, 81x, and 82x
must have an admission date.
4. Type of bills 11x, 12x, 18x 21x, and 22x must have a type
of admission.
5. If applicable, include the attending, ordering, or operating
physician NPIs, as well as facility NPIs.
6. Ensure that the days reported match the statement
covers dates.
7. Verify that the ICD-10 procedure code date submitted is within
the statement dates/admit dates.
8. Type of bill 13x should include a patient reason for visit.
9. Do not submit duplicate diagnosis codes on the same claim.
10. Do not submit claims with dates of service after 12/31/2015.
Do not submit a date of service earlier than October 1, 2015
for test claims that contain ICD-10 codes.
Do not bill ICD-9 and ICD-10 codes on the same claim.
Ensure test claims contain both the National Provider
Identifiers (NPIs) and corresponding Provider Transaction Access
Numbers (PTANs) that you told your MAC you
would use for testing.
Ensure the rendering provider corresponds with the correct billing
provider submitted during the volunteer process.
Ensure test claims contain the Health Insurance Claim Number
(HICNs) that you told your MAC you would test with and ensure
they are active, valid HICNs (not for deceased patients).
Ensure the patients name matches the HICN.
Submit a variety of claims that best represents your business and
utilizes the various code types (i.e. procedure codes, principal
diagnosis, admitting diagnosis, patient reason for
visit, and external cause of injury).
Dont forget the 0 or 9 qualifier code to identify ICD-9
and ICD-10 claims.
Consider submitting multiple detail lines of service on
each claim.
Submit procedure codes and ICD-10 diagnoses codes that
have specific medical necessity requirements as outlined in
Local Contractor Determinations (LCDs), National Coverage
Determinations (NCDs), or other local coverage policies your
MAC may have in place.
 ICD-10 End-to-End Testing Checklist
Consider choosing patients who have different billing
situations (i.e. Medicare as the secondary payer (MSP),
Coordination of Benefits (COB), Medicaid crossover claim,
hospice, and Health Maintenance Organization (HMO)) in
addition to traditional Medicare.
Avoid submitting claims for the same patient for the same date of
service AND procedure code. The claim will deny as a duplicate.
Do not use the same diagnosis code as your principal/primary
diagnosis code for each test claim.
Ensure claims for date of service October 1, 2015 and after are
billed with an ICD-10 code and Diagnosis Qualifier/Indicator 0.
Dates of service September 30, 2015 and prior must be billed with
an ICD-9 code and Diagnosis Qualifier/Indicator 9.
Consider submitting the maximum number of ICD-10 diagnosis
codes per claim. ICD-10-CM codes can have from 3 to 7
characters. You must report all of the characters. For instance, if
the ICD-10-CM code is 7 characters long, then you must report all
7 characters.
If you tested in a previous end-to-end testing week, ensure your
claims for this testing week do not duplicate previously processed
claims. It is acceptable to resubmit corrected claims from the
previous testing week that were return to provider (RTP).
Home Health
Revenue code 0023 must be reported with appropriate Health
Insurance Prospective Payment System (HIPPS) code.
Must have an attending physician.
Treatment authorization code must be present.
Value code 61 must be billed with Core-Based Statistical
Area (CBSA) code of the service location.
Final claims (other than LUPAs) must also have a matching RAP.
Skilled Nursing Facility (SNF)/Swing bed
A 3-day inpatient qualifying stay needs to be on file.
Revenue code must be 0022 with an appropriate HIPPS code.
Need room and board revenue code (units on both revenue code
0022 and room and board must match.
A HIPPS code of anything other than AAAxx will need at least one
occurrence code 50.
Hospice
Claims ONLY should be submitted. NOEs will be entered by the
MAC, since hospices will not have DDE access.
Value code should be 61 with CBSA code of home service location
with revenue code 0651 or 0652.
Value code should be G8 for location of inpatient services with
revenue code 0655 or 0656.
End Stage Renal Disease (ESRD)
Only one condition code, 70-76 can be present on the claim.
Value codes must be A8, A9 and D5 with appropriate amounts.
Institutional Providers
Revenue codes must be 821, 831, 841 or 851.
Healthcare Common Procedure Coding System (HCPCS)
90999 must be billed with revenue code 82x and appropriate
G-modifier (G1-G6).
Primary diagnosis code must be a Chronic Renal Failure
diagnosis code.
Acute Care Inpatient (IPPS)
Revenue code must be included for room and board.
Value codes must be 80 (covered days), 81 (non-covered days), 82
(coinsurance), 83 (life time reserves), 09 (1st year coinsurance), 11
(2nd year coinsurance), 08 (1st year lifetime reserve days), or 10
(2nd year lifetime reserves).
Include a Present on Admission (POA) indicator and remember
that a code exempt from POA should not have a POA indicator
submitted. The 2015 ICD-10-CM POA Exempt list can be found
at http://www.cms.gov/Medicare/coding/ICD10/2015-ICD-10-CM-
and-GEMS.html (the last Downloads document).
Inpatient Rehab Facility
The same requirements as acute care inpatient above
apply except:
-- Revenue code will be 0024 with valid HIPPS
Federally Qualified Health Clinic (FQHC)
Encounter/visits must be billed under revenue code 052x.
Telehealth must be billed with revenue code 0780 and
HCPCS Q3014.
Mental health treatment should be billed with revenue
code 0900.
Diabetes self-management training and medical nutrition
therapy should be billed with revenue code 052x with
procedure codes G0108 or 97802.
Ambulance
Type of bill should be 13x, 22x, 23x, and 85x.
Revenue code should be 054x.
Bill with the appropriate ambulance HCPCS and units.
Make sure there is an appropriate origin and
destination modifier.
Submit value code AO with the zip code of the pickup location.
Therapy Claims
Physical therapy services require revenue code 42x, GP modifier,
occurrence code 11, 29 and 35.
Occupational therapy services require revenue code 43x, the GO
modifier, occurrence code 11, 17, and 44.
SLP services require revenue code 44x, GN modifier, occurrence
code 11, 30, and 45.
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 ICD-10 End-to-End Testing Checklist
HOW TO AVOID RETURN TO PROVIDER CLAIMS
Claims which have errors and return to provider (RTP) will not
produce a remittance advice. Below are helpful hints to avoid these
claims during ICD-10 testing:
1. The spelling of the beneficiarys name and the HICN must match
Medicares master eligibility record.
2. The number of days represented by the from and through
dates on the claim must be counted correctly. If the dates are not
the same on the inpatient hospital or SNF claims, the number of
days represented must equal the sum of the covered days plus
the non-covered days unless the patient status is 30, in which
one additional day is used for the calculation.
3. External causes of injury are no longer reported with E-codes in
ICD-10. Only diagnosis codes V00.01A-Y99.9 are accepted on
ICD-10 claims.
4. The admitting diagnosis field for the date of service must be a
valid diagnosis code for the date of service.
5. Ensure that the admission date equals the statement to date on
a Prospective Payment System (PPS) claim.
6. Check that claims billed with an ICD-10 diagnosis code do not
have statement from and to dates prior to October 1, 2015.
Any date prior to October 1, 2015 must be billed with an ICD-9
diagnosis code.
7. The covered days on a claim should be numeric or blank.
8. Bill with valid procedure codes.
9. Sometimes claims are rejected because there is a cross
referenced claim and the type of bill needs to be adjusted or
cancelled. Avoid these situations by minimizing adjustments bill
types (117) or sequential billing that may cause claims to RTP if
prior claims are not finalized history.
10. The from date is after the admit date and the system is
looking for another claim in order to be processed. For testing
purposes, make sure the admit date is equal to the from date
on inpatient claims. Once again, all claims should be original bill
and make sure the admission and from dates are valid.
AFTER SUBMITTING TEST CLAIMS
As Remittance Advices (RAs) are produced, check them daily to
identify any discrepancies that have occurred and contact your MAC
accordingly.
Institutional Providers
ADDITIONAL RESOURCES
Centers for Medicare & Medicaid Services Resources
CMS has developed timeline resources, checklists, and provides
various resources to help the health care industry transition to
ICD-10 by the October 1, 2015, deadline.
CMS ICD-10
http://www.cms.gov/Medicare/Coding/ICD10/index.html
ICD-10 Final Rule
http://www.cms.gov/Medicare/Coding/ICD10/Statute_
Regulations.html
Latest News
http://www.cms.gov/Medicare/Coding/ICD10/Latest_News.html
Provider Resources
http://www.cms.gov/Medicare/Coding/ICD10/Provider
Resources.html
Frequently Asked Questions
A listing of ICD-10 frequently asked questions is available on
the http://www.cgsmedicare.com/parta/FAQs/index.html of the
CGS website.
MLN Matters Articles
MM7492: Medicare Fee-For-Service (FFS) Claims
Processing Guidance for Implementing ICD-10
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNMattersArticles/downloads/MM7492.pdf
MM8465: International Classification of Diseases,
10th Revision (ICD-10) Testing with Providers through
the Common Edits and Enhancements Module (CEM)
and Common Electronic Data Interchange (CEDI)
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNMattersArticles/Downloads/MM8465.pdf
SE1239: Updated ICD-10 Implementation Information
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNMattersArticles/downloads/SE1239.pdf
SE1240: Partial Code Freeze Prior to ICD-10 Implementation
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNMattersArticles/Downloads/SE1240.pdf
SE1409: Medicare Fee-For-Service (FFS)
International Classification of Diseases,
10th Edition (ICD-10) Testing Approach
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNMattersArticles/Downloads/SE1409.pdf
MLN Matters Fact Sheets
ICD-10-CM/PCS: The Next Generation of Coding
http://www.cms.gov/Medicare/Coding/ICD10/downloads/ICD-
10Overview.pdf
ICD-10-CM/PCS: Myths and Facts
http://www.cms.gov/Medicare/Coding/ICD10/downloads/ICD-
10MythsandFacts.pdf