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2013-03 CR 8197 Medicare Shared Systems ICD-9 to ICD-10

Jurisdiction 11 Part B
International Classification of Diseases (ICD)-10 Conversion from ICD-9 and Related Code Infrastructure of the Medicare Shared Systems as They Relate to CMS National Coverage Determinations (NCDs)

MLN Matters® Number: MM8197 Related Change Request (CR) #: CR 8197 Related CR Release Date: March15, 2013 Effective Date: Please note that the implementation date is prior to the effective date in order to be prepared to meet the timeline to implement the new ICD-10 diagnosis codes on October 1, 2014. The shared systems began implementation of the necessary changes to the NCDs in the January 2013 systems release with CR 7818, followed by CR 8109 in the April 2013 release, and finishing up with this CR split between the July 2013 and October 2013 releases (analysis and design/implementation). Related CR Transmittal #: R1199OTN Implementation Date: July 1, 2013

Provider Types Affected
This MLN Matters® article is intended for physicians, other providers and suppliers submitting claims to Medicare Contractors (Carriers, Fiscal Intermediaries (FIs), Medicare Administrative Contractors (A/B MACs) and Durable Medical Equipment Medicare Administrative Contractors, (DME MACs) for services to Medicare beneficiaries.

Provider Action Needed
Change Request (CR) 8197, from which this article is taken, creates and updates National Coverage Determination (NCD) hard-coded shared system edits that contain International Classification of Diseases (ICD)-9 diagnosis codes with the comparable ICD-10 diagnosis codes, along with all related coding infrastructure such as procedure codes, Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) codes, messages, frequency edits, Place of Service/Type of Bill (POS/TOB), provider specialties, etc.

The requirements it describes reflect the operational changes that are necessary to implement the conversion of the Medicare shared system coding from ICD-9 to ICD-10 specific to 30 NCDs that are attachments to CR 8197.

In order to be prepared to meet the timeline to implement the new ICD-10 diagnosis codes on October 1, 2014, the shared systems began implementation of the necessary changes to the NCDs in the January 2013, quarterly release with CR 7818, followed by CR 8109 in the April 2013, quarterly release and culminates with this CR split between the July 2013, and October 2013, quarterly releases.

See the Background and Additional Information sections of this article for further details regarding these changes, and be sure that you are ready for ICD-10 implementation by October 1, 2014.

As announced in CMS-40-F, 45 CFR Part 162 (CMS–0040–F) RIN 0938–AQ13, ‘Administrative Simplification: Adoption of a Standard for a Unique Health Plan Identifier; Addition to the National Provider Identifier Requirements, and a Change to the Compliance Date for the International Classification of Diseases, 10th Edition (ICD–10–CM and ICD–10–PCS) Medical Data Code Sets’ (September 5, 2012), effective October 1, 2014, all Medicare claims submissions will convert from the 9th Edition (ICD-9) to the 10th Edition (ICD-10).

(You can find this document at http://www.gpo.gov/fdsys/pkg/FR-2012-09-05 on pages 54663 through 54720.)

All Health Insurance Portability and Accountability Act (HIPAA)-covered entities must adhere to the conversion, which will require business and systems changes throughout the health care industry. In accordance, per the ICD-10 Final Rule, published in the January 16, 2009, Federal Register, (see http://www.gpo.gov/fdsys/pkg/FR-2009-01-16/pdf/E9-740.pdf). The Secretary of the Department of Health and Human Services adopts the ICD-10-CM and ICD-10-PCS code sets for use in appropriate HIPAA standard transactions (including those submitted in both electronic and paper formats) effective October 1, 2014.

General Information Found in Spreadsheets in the Attachments
Thirty spreadsheets are attached to CR 8197 indicating certain affected ICD-9 codes and their corresponding ICD-10 codes as they relate to their respective NCDs, in addition to the rest of the coding infrastructure specific to each NCD.

Each spreadsheet contains the following information:
NCD Number/Title
Internet-Only Manual (IOM) searchable link related to the NCD
Medicare Coverage Database (MCD) searchable link related to the NCD

Within each spreadsheet, there are three tabs:
ICD Diagnosis
Rule Description

Spreadsheets attached to CR 8197 explain the following NCDs:

20.4 Implantable Automatic Defibrillator 20.7 Percutaneous Transluminal Angioplasty 20.16 Cardiac Output Monitoring by Thoracic Electrical Bioimpedance 20.30 Microvolt T-Wave Alternans 20.31 Intensive Cardiac Rehabilitation Programs 20.31.1 The Pritikin Program 20.31.2 Ornish Program for Reversing Heart Disease 40.1 Diabetes Outpatient Self-Management Training 40.7 Outpatient Intravenous Insulin Treatment 50.3 Cochlear Implantation 100.14 Surgery for Diabetes 110.4 Extracorporeal Photopheresis 110.8.1 Stem Cell Transplantation 150.10 Lumbar Artificial Disc Replacement 180.1 Medical Nutrition Therapy 190.1 Histocompatibility Testing 190.3 Cytogenetic Studies 190.5 Sweat Test 190.8 Lymphocyte Mitogen Response Assays 190.11 Home Prothrombin Time/International Normalized Ratio Monitoring for Anticoagulation Management 210.2 Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer 210.4 Smoking and Tobacco-Use Cessation Counseling 210.4.1 Counseling to Prevent Tobacco Use 210.7 Screening for the Human Immunodeficiency Virus Infection 210.10 Screening for Sexually Transmitted Infections and High-Intensity Behavioral Counseling to Prevent STIs 220.4 Mammograms 220.6.16 FDG PET for Infection and Inflammation 220.6.19 Positron Emission Tomography (NaF-18) to Identify Bone Metastasis of Cancer 260.1 Adult Liver Transplantation 260.9 Heart Transplants

Should your contractor deny claims associated with the NCDs addressed by CR 8197, they will use:
Group Code PR (Patient Responsibility) assigning financial responsibility to the beneficiary (if a claim is received with a GA modifier indicating a signed Advance Beneficiary Notice of Noncoverage (ABN) is on file)
Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file)
Claim Adjustment Reason Code (CARC) 50: These services are non-covered services because this is not deemed a ‘medical necessity’ by the payer

Additionally, where appropriate and not specifically indicated in the various attached spreadsheets, they will use:

Remittance Advice Remark Code (RARC) N386: This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx on the CMS website.

Additionally, NCD 190.11 includes a change to CR 6313 dated January 8, 2009, and is also a change to the spreadsheet attached to CR 8109/TR1162.

Likewise, NCD 110.4 includes a change to CR 7806/TR2551 correction dated September 24, 2012, that removed 996.88 from CR 7806 dated August 3, 2012, and a change to the spreadsheet attached to CR 7818 dated September 14, 2012.

Additional Information
The official instruction, CR 8197 issued to your Carrier, FI, A/B MAC or DME MAC regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1199OTN.pdf on the CMS website.

You will find spreadsheets that contain all affected ICD-9 codes and their corresponding ICD-10 codes as they relate to their respective NCDs, in addition to the rest of the coding infrastructure specific to each NCD as attachments the this CR.

This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2012 American Medical Association.

last updated on 03/25/2013