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Knowledge Center

Episode 162: Workgroup Voices, The Inner Workings of Prior Authorization

February 24, 2015

This white paper provides a starting point for small physician practices performing ICD- 10 testing. (CMS defines a small physician/provider practice as having one to five physicians providing single or multi-specialty services.) This paper categorizes testing tasks under who, what, where, when, why and how categories. It focuses on providers’ external testing with payers and assumes providers’ internal systems are ready for ICD- 10. It generally assumes providers do not use a billing service. Those who do should account for that when using this information (i.e., coordinate as needed with a billing service in addition to or instead of working directly with payers and/or clearinghouses).

ICD-10, which will replace ICD-9 code sets and update ICD-9 terminology, consists of two parts: (1) ICD-10-CM will be used for diagnosis coding for all claims, and (2) ICD- 10-PCS will be used for procedure coding on inpatient hospital claims. The compliance date is October 1, 2015. Additional background is available in documents listed in the appendix.

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