ICD-10 Conversion Guidelines — Use of Unspecified Diagnosis Codes, Specificity, and Prior Authorization Requirements
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Guidance from Hawaii Department of Human Services Med-QUEST Division on acceptable ICD-10 diagnosis code use, specificity expectations, and prior authorization requirements affecting QUEST Integration, Fee-For-Service, and Community Care Services LTSS/HCBS providers.
No material clinical or coverage changes in this revision.
ICD-10 Coding Requirements for LTSS/HCBS
ICD-10 coding and PA criteria for LTSS/HCBS
Requirements and MQD stance for ICD-10 diagnosis coding on claims and LTSS/HCBS prior authorizations:
Unspecified Codes and Specificity Guidance
| R69 | Illness, unspecified (ICD-10 unspecified diagnoses code) - not accepted beginning October 1, 2015 except for transportation and interpretation services |
Prior Authorization and Documentation Actions for Providers
Prior authorizations must include beneficiary‑specific ICD‑10 code(s)
LTSS/HCBS prior authorizations issued by health plans for services on or after October 1, 2015 must include at least one appropriate beneficiary-specific ICD-10 diagnosis code; more than one ICD-10 code may be used. The ICD-10 diagnosis codes used must relate to the persistent clinical reasons the beneficiary qualified for LTSS/HCBS. Health plans should not tell providers specific diagnosis codes to use for a specific claim/beneficiary.
- At least one beneficiary-specific ICD-10 code is required on PAs for LTSS/HCBS services dated October 1, 2015 forward.
- Multiple ICD-10 codes may be listed if appropriate.
- Codes must relate to the persistent clinical reasons the beneficiary qualified for services.
Prior authorizations can be used to document beneficiary diagnosis for claims
An appropriate prior authorization issued by a health plan to an LTSS/HCBS provider can satisfy the requirement to have a medically appropriate, beneficiary‑specific ICD‑10 diagnosis code on claims.
- PAs that include beneficiary‑specific ICD‑10 code(s) may be used to document the diagnosis for claim submission.
- Providers still must use a medically appropriate, beneficiary‑specific ICD‑10 code on all claim bills beginning October 1, 2015.
Key Terms and Code Definitions
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