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Workers’ Compensation and ICD-10

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workers comp ICD10 hisAll medical providers are preparing to switch their billing practices from ICD-9 coding to ICD-10 as mandated by the Health Insurance Portability Accountability Act of 1996 (HIPPA).

workers comp ICD10 hisAll medical providers are preparing to switch their billing practices from ICD-9 coding to ICD-10 as mandated by the Health Insurance Portability Accountability Act of 1996 (HIPPA).  The change is to take place on October 1, 2014.

Workers’ compensation commercial insurers are non-covered entities under HIPPA and therefore exempt from the mandate to convert their billing practices to ICD-10.  This has created some confusion and concern as to what the impact will be on processing claims submitted by medical service providers who treat a large number of worker’s compensation patients.

Workers’ compensation programs are state run programs governed by the laws and regulations of each state.  Even though different states have different rules and regulations, all states require employers to provide complete coverage for medical treatment of work-related injuries. Each state sets its own fee schedule and does not allow a medical service provider to bill patients for any balance above and beyond the fee established by that schedule.

Some states have state-managed insurers and require employers to use them.  Others allow national or local insurers to underwrite the workers’ compensation insurance.  States also have different guidelines concerning the electronic submission of claims and the use of electronic health records (EHR).  It is expected that the insurers in those states who use EHR will adopt the ICD-10 format for processing claims.  The problem comes with smaller insurance companies that do not or cannot currently accept electronic claims.

Some workers’ compensation insurers have already confirmed they will accept electronic claims and adopt ICD-10 for claims processing.  The Centers for Medicaid and Medicare Services (CMS) is working with all non-covered entities, including workers’ compensation insurers, to encourage and assist with transitioning from ICD-9 to ICD-10.

Some of the reasons for using ICD-10 even when not mandated are:

• Medical service providers are required under HIPAA to convert from ICD-9 to ICD-10.  Using two billing systems will not be practical for them.  They will refuse to take worker’s compensation cases if it means having a separate billing system and this will compromise the overall care of injured workers.

• The new system actually provides more detailed billing and specificity about treatment provided.  This provides useful information when developing patterns of care.

Anthem Workers’ Compensation announced it will begin using ICD-10 on October 1, 2014, even though it is a non-covered entity.  In addition to the reasons already stated, some additional reasons Anthem gives for its decision are:

• It is an international billing system that allows consistent billing across borders.

• It lists more diagnoses with more specificity.

• Epidemiological tracking is improved with more specificity.

• Uses current technology and updated terminology.

• Contains detailed information about procedures with details about the anatomical site involved and methods used in treating the condition.

• It allows better tracking of patient outcomes.

One big hurdle to nationwide adoption of ICD-10 billing for workers’ compensation is that the way some state statutes are written, legislative changes will need to be made before the insurers are allowed to fully adopt the new billing system.  Since there are so many advantages to adopting the new system even though exempt, it is expected that within two years, workers’ compensation insurers will be on board and implementing the change.


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