FREQUENTLY ASKED QUESTIONS REGARDING ICD 10 CODES - Interpharm

FREQUENTLY ASKED QUESTIONS REGARDING ICD 10 CODES 1. What is ICD-10? ICD-10 stands for “International Classification of Diseases and Related Health Problems – version 10”. This is a set of codes which translates the written description of a diagnosis into a coded format e.g. acute tonsillitis = J03.9. This set of codes form part of an international standard of diagnostic codes and is owned and maintained by the World Health Organisation. 2. Why do we need ICD-10 codes? In the past, providers of health services such as General Practitioners (GPs) described diagnoses each in their own way. This made it impossible to use uniform diagnoses and as a result, it was decided to standardize the diagnoses. The National Department of Health and the Council of Medical Schemes had driven a process to formalise ICD-10 as the diagnostic coding standard for South Africa as part of the legislative requirements of the Medical Schemes Act. The benefits to the medical industry of using ICD-10 codes are numerous, but the most pertinent include: • • •

Appropriate management of medical services and benefits Faster payment of claims Disease profiling which will allow for improved research and treatment plans

3. Where will ICD-10 be implemented? ICD-10 will apply to all members of the healthcare profession within South Africa.. 4. Who will be required to use ICD-10? As per the regulations of the Medical Schemes Act, all providers of healthcare such as hospitals, doctors, allied professionals, etc. will be required to make use of ICD-10 codes 5. Will all healthcare professionals be required to submit ICD-10 codes? In accordance with the Medical Schemes Act all healthcare professionals are required to provide ICD-10 codes. 6. When did the submission of ICD-10 codes became mandatory? The official date on which the legislation of ICD-10 came into effect was 1 January 2005. 7.

Will all conditions require ICD-10 coding?

Yes, with effect from 1 January 2005 the full ICD-10 coding system will be implemented in contrast to 2004 where ICD-10 codes were only required for the 25 conditions on the Chronic Disease List. 8. Will the implementation of ICD-10 codes be restricted to the private sector only? No, ICD-10 codes will be implemented in both the private and public sector.

9. Will claims be rejected if submitted without ICD-10 codes with effect from 1 January 2005? No, claims will not be rejected. All claims submitted without ICD-10 codes or invalid ICD-10 codes will be processed as normal but returned to providers with information messages and error codes highlighting the need to submit ICD-10 codes. This process will be followed from 1 January 2005 – 28 February 2007. 10. Has any scheme within the Medscheme stable commenced with the rejections of claims if submitted without valid ICD-10 codes? Yes, Massmart Health Plan commenced with rejections on 1 April 2006. 11. When will the remainder of the schemes within the Medscheme stable commence with the rejection of claims if submitted without invalid ICD-10 codes? Medscheme will be following a phased-in approach and rejections will be implemented per discipline concentrating on disciplines which have the highest ratio of PMB claims Claims will be rejected per discipline group on the following basis: if ICD-10 code is omitted from claim line if ICD-10 code is invalid. 12. How and when will Medscheme’s rejection strategy be implemented? The rejection strategy will be implemented as follows: Phase 1

Specialist Physician Cardiology

Effective date March 2007 018 021

Psychiatry

Phase 2

Effective date May 2007

Phase 3

Effective date July 2007

072 054

Phytotherapy Oral Pathology

103 098

022

Physiotherapy General Dental Practice Dieticians

084

076

Rheumatology

031

Anaesthetists

010

Pulmonology

017

Paediatricians

032

Neurology Urology

020 046

070 088

Ophthalmology

026

Optometrists Registered Nurse Radiography

Unattached operating theatres/Day Clinics Private Rehab Hospital (acute) Drug & Alcohol Rehabilitation Hospices Sub- acute facilities

039

055

Gastroenterology

019

Dermatology

012

Obstetrics & Gynaecology

016

Mental health Institutions Paediatric Cardiology Periodontics Clinical Haematology Clinical Services Neurosurgery Maxillo-facial & Oral Surgery

059 047 079 049

033 092 027 090 024 062

Approved UOTU/Day Clinics Occupational Therapy Dental Therapy Foreign Services & internal practices Psychologists Otorhinolaryngology Private Hospital (A Status) Surgery/ Paediatric Surgery Orthopaedics Private Hospital (B Status) Optical Dispensers Social Workers Cardio Thoracic Surgery Group Practice Speech therapy & Audiology Ambulance Services Advanced Prosthodontics Nuclear Medicines Homeopaths Orthotists & prosthetists Medical oncology Chiropractors Orthodontics Clinical Technology Radiation oncology/Nuclear Medicine/Oncology Orthoptists Blood & Blood Products courier Nursing Agencies/ Home Care Service Audiology Group practice Hospitals Provincial hospitals Blood Transfusion Services Naturopathy Psychometry Medical Scientists Community Dentistry Community Health

077 066 095 006 086 030 057 042 028 058 071 089 044 050 082 009 094 025 008 087 023 004 064 075 040 074 003 080 083 051 056 078 101 085 069 096 097

Ambulance serviceIntermediate Art Therapists Phase 4 General Medical Practice Phase 5 Pharmacies Pathologists Diagnostic Radiologists Phase 6 Namibian Practitioner Ambulance Services Basic Independent Occupational Specialists Physical Medicine Plastic & Reconstructive Surgery Travel Clinic Pharmocotherapist Podiatry Masseurs Registered Counsellors Ambulance Services - other Dental Technology Osteopathy Ayurveda Practitioner Acupuncturist Therapeutric Aroma therapist Therapetic Massage Therapist Therapetic Reflexologist

Effective date 1 August 2007 14/15 Effective date 1 October 2007 060 052 038 Effective date 1 December 2007 007 013 029 034 036 048 061 068 073 081 091 093 102 104 105 106 107 108

011 067

13. How will the phased rejection strategy be communicated to the Healthcare Professionals? Healthcare Professionals will be informed via the following means: . • E-mail • Emailedv- With Remittance Advice • Posted in Remittance Advice • As abbreviated messages on Remittance Advices • Articles in Good Practice • Posted on website 14. At which level must Healthcare Professionals need to supply ICD-10 codes? Healthcare Professionals need to supply valid and complete ICD-10 codes which means rd th that any code must be coded to its highest level of specificity at its appropriate 3 , 4 or th 5 character level. . 15. Will the privacy, confidentiality and security of member information be jeopardised through the submission of ICD-10 codes? No, ICD-10 codes will be handled in the same confidential manner as is currently the case with members’ personal details and clinical information contained on medical accounts to ensure the continued privacy and security of member information. 17. Are ICD-10 codes required on line level for hospital claims? No, ICD-10 codes must only be supplied on header level in respect of hospital claims. 18. How are multiple ICD-10 codes on line level differentiated from one another? The forward slash (/) is used as a delimiter.