Wiki Is a TPA in compliance if they convert ICD-10 coded claims to ICD-9 before processing

[Marcia Cox]

This is a first for me but wondering if anyone can comment on this. I work with a TPA (Third Party Administrator) for a large employer group who recently told me that they have not converted their system from ICD-9 to ICD-10 (which I thought everyone was required to do in 2015). When they receive claims from medical providers the TPA compares the ICD-10 DX and chooses the closest ICD-9 DX to consider the claim for payment. This doesn't seem like it would be compliant. Any comments or suggestions on where I research this?

 

[mitchellde]

This is a first for me but wondering if anyone can comment on this. I work with a TPA (Third Party Administrator) for a large employer group who recently told me that they have not converted their system from ICD-9 to ICD-10 (which I thought everyone was required to do in 2015). When they receive claims from medical providers the TPA compares the ICD-10 DX and chooses the closest ICD-9 DX to consider the claim for payment. This doesn't seem like it would be compliant. Any comments or suggestions on where I research this?

You need to check to see if your TPA is required to be HIPAA compliant. For instance workers comp is not required to be HIPAA compliant. HIPAA compliance requires the use of current code sets.

 

[thomas7331]

It's my understanding that the HIPAA laws that govern the code sets that can be used only extend to the use of those codes within the electronic claims transactions. I don't think there is a compliance problem using different codes within an entity's own processing system as long as those codes are not used in HIPAA covered transactions and not used to report health data external to the entity using them.