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ICD-10                                                                                                    Page Last Updated:  8/8/2016

Production Prior Authorization Submissions
Prior Authorization records submitted with requested effective dates of 10/1/15 or greater should be submitted with an ICD-10 diagnosis code.

The International Classification of Diseases, 10th Revision (ICD-10) medical coding system is mandated for use by the U.S. Department of Health and Human Services
Centers for Medicare and Medicaid Services (CMS); replacing ICD-9 CM codes (volumes 1-3). Due to the enhanced specificity and level of detail of the ICD-10 code set, the transition is anticipated to have a impact on the Alabama Medicaid program, health care providers and trading partners. ICD-10 Clinical Modification (CM) and the ICD-10 Procedure Code System (PCS) codes will improve the ability to monitor the incidence and prevalence of diseases, track treatment and health care delivery, and prepare for Electronic Health Record (EHR) use.

For further guidance please visit the CMS website, http://www.cms.gov/ICD10

Provider Electronic Solutions (PES) Software
The Provider Electronic Solutions (PES) Software that includes modifications for ICD-10 is now available. Please refer to Appendix C Change Log in the PES User Manual for a full list of the changes included in the new PES version. Please note the following:

  • PES version 3.02 includes changes for ICD-10.
  • The upgrade process will set all previous Claim and Prior Authorization ICD versions to ICD-9 (‘9’).
  • The ICD version field on new Claims and Prior Authorizations will default to ICD-9 (‘9’).
  • The Procedure/HCPCS list has been split into multiple lists: 
        - Procedure HCPCS (non-surgical procedure codes)
        - Procedure ICD-9 (surgical procedure codes)
        - Procedure ICD-10 (surgical procedure codes)
  • Procedure codes currently entered on the ‘Procedure/HCPCS’ list will be moved to both ‘Procedure HCPCS’ AND “Procedure ICD-9’ when an upgrade to version 3.02 is performed. Users will need to remove invalid codes from each respective list.
  • The Diagnosis list has been split into multiple lists:
        - Diagnosis ICD-9
        - Diagnosis ICD-10
  • Diagnosis codes currently entered on the diagnosis list will be moved to the new ‘Diagnosis ICD-9’ list when an upgrade to version 3.02 is performed.
  • Users may begin building ICD-10 lists now. ICD-10 codes should not be submitted until the CMS mandated date.
  • Provider Electronic Solutions Software