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Rejected or Denied Claims: ICD-10 Troubleshooting Guide

Brooke Phillips, CWCMS
Editor | Shield HealthCare
12/08/15  4:49 PM PST
ICD-10 Troubleshooting

As of October 1, 2015, CMS required the healthcare industry to transition to the new 7-digit ICD-10 coding system.  The number of diagnosis codes went from roughly 14,000 ICD-9 codes to 68,000+ ICD-10 codes. These additional codes allow for more specificity in diagnosing the condition of the individual, enabling reporting of laterality (right vs. left designations) and modernizing the terminology to reflect current medical standards. The new coding system is also more flexible, allowing the codes to adapt as new conditions are discovered, and as new treatments and medical devices are developed.

By now your practice has gained some experience in submitting claims with ICD-10 codes. So what’s next?

Determine if your claims will be paid, rejected or denied with this ICD-10 Troubleshooting Guide:

Paid Claims:  Insurance carrier EOB’s/remittance advice will provide you an early indication that your claim has paid. If you submitted claims early in the month this information should be available and be routinely validated by your office.

Rejected Claims:  A claim that is rejected does not meet the claim submission requirements to pass the claim edits, will not be considered received, and will not be processed by the payer. You should be checking your mail for carrier remittance advice for rejected claims. Be aware of timely filing rules to ensure rejected claims are resent in the acceptable filing period.

Denied Claims:  A claim that is denied has passed the claim edits, has been received by the payer and a payment determination has been issued. You should be reviewing your carrier remittance advice for ICD-10 related claim denials.

Rejected Claims:

Rejected ICD-10 Claims

Denied Claims:

Denied ICD-10 Claims


Don’t forget to resubmit your claim once you have made the required updates!!!

You should continuing monitoring your insurance carriers for updates on ICD-10. Most insurance carriers are providing listings on the most common errors. CMS continues to provide regular updates on their website: www.cms.gov/Medicare/Coding/ICD10/Medicare-Fee-For-Service-Provider-Resources.html

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