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Wisconsin DHS will enforce ICD-10 code specificity for Medicaid beginning Oct. 1

On Oct. 1, 2015, all HIPAA-covered entities will be required to transition to ICD-10. Although the Centers for Medicare and Medicaid Services (CMS) has indicated that Medicare will relax its enforcement of specificity on ICD-10 claims for 12 months, the Wisconsin Department of Health Services (DHS) will enforce the code specificity for Medicaid claims beginning Oct 1.

According to the DHS, claims without this detail will be denied and prior authorization (PA) requests without this detail will be returned. These claims and PA requests will then need to be resubmitted with a specific ICD-10 code in order to be processed. These also may be subject to audit and recoupment if the correct specificity is not applied.

ForwardHealth is currently conducting ICD-10 testing with all interested stakeholders. The DHS strongly encourages providers to test claim submissions in order to assess their ICD-10 readiness. Information about testing is available on this ICD-10 Code Set Testing page, at the ForwardHealth Portal.

With the new code set, diagnosis codes must be coded to the highest level of specificity and accurately assigned to the claim in order to support medical necessity, avoid claim denials and ensure appropriate reimbursement. More information about code set specificity and enforcement is available in this ForwardHealth Update, as well as this article in the Wisconsin Medical Society’s Practice Vitals newsletter.

A number of additional educational tools and resources to assist with the ICD-10 transition are available on the ForwardHealth Portal Code Set Transition page, the CMS website, the Society’s website and through the Society’s Continuing Education Center.

Questions may be directed to VEDSICD10Support@wisconsin.gov.

Back to September 3, 2015 Medigram