Countdown to ICD-10-CM

ICD-10 implementation is only one month away!  The Centers for Medicare and Medicaid Services (CMS) recently posted clarifications to commonly asked questions.   The countdown begins!

5. Is there a delay in implementation?

No.  Per CMS, “Medicare claims with a date of service on or after October 1, 2015, will be rejected if they do not contain a valid ICD-10 code. The Medicare claims processing systems do not have the capability to accept ICD-9 codes for dates of service after September 30, 2015, or accept claims that contain both ICD-9 and ICD-10 codes for any dates of service.”

4. What is a valid ICD-10 code?

Per CMS, “ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters.”  It is required that all ICD-10 codes be coded to the highest level of specificity, or the claim will not be processed by Medicare.  A complete list of 2016 ICD-10-CM valid codes and code titles is posted on the CMS website.

3. What are the recently announced “flexibilities”?

CMS indicated that “for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.” 

“Family of codes” indicates that the codes are in the same ICD-10 three character category and are clinically related.  For example, if the code documented is “Crohn’s disease of small intestine without complications” K50.00, and the code billed is “Crohn’s disease, unspecified, without complications” K50.90, then the code will not be denied in an audit because it is in the same family, “K50”.  This is referred to as “audit flexibility”.  CMS emphasizes that every code must be valid. 

2. Local Coverage Determinations (LCD) and National Coverage Determinations (NCD) frequently indicate medically necessary diagnosis code requirements.  Does the recent guidance mean the published NCD’s and LCD’s will be changed to include families of codes rather than specific codes?

Per CMS, No. The flexibility determination will be used when Medicare review contractors audit claims.   Medicare review contractors include the Medicare Administrative Contractors, the Recovery Auditors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor.  There will be no leniency in NCD and LCD interpretation.

1. What is the ICD-10 Ombudsman?

“CMS will have an ICD-10 Ombudsman to help receive and triage physician and provider issues.  The Ombudsman will work closely with representatives in CMS’s regional offices to address physicians’ concerns. As we get closer to the October 1, 2015, compliance date, CMS will issue guidance about how to submit issues to the Ombudsman.”