New CMS Guidance for First Year of ICD-10

The Centers for Medicare and Medicaid Services (CMS) has issued a Frequently Asked Questions document developed in conjunction with the American Medical Association (AMA) entitled: CMS and AMA Announce Efforts to Help Providers Get Ready For ICD-10 Frequently Asked Questions.  The most critical item in the document states:

Q2. What happens if I use the wrong ICD-10 code, will my claim be denied?

A1. While diagnosis coding to the correct level of specificity is the goal for all claims, 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. However, a valid ICD-10 code will be required on all claims starting on October 1, 2015. It is possible a claim could be chosen for review for reasons other than the specificity of the ICD-10 code and the claim would continue to be reviewed for these reasons. This policy will be adopted by the Medicare Administrative Contractors, the Recovery Audit Contractors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor. (Source: CMS website)

In other words, Medicare will not deny payment during this one-year period as providers adapt to the new system.  ICD-10 has a much higher degree of complexity and specificity in the coding hierarchy which will take some time for providers used to ICD-9 to fully navigate.  The critical issue is that the claim contains a code from the correct family of codes.

Other issues agreed to by CMS and the AMA include:

-       Exempting physicians from Physician Quality Reporting System, Value Based Modifier, or Meaningful Use 2 penalties as long as they use a code from the correct code family is used;

-       CMS may authorize advance payments to physicians if Medicare contractors are unable to process claims due to problems with ICD-10; and

-       The creation of an ICD-10 communications center and ombudsman to monitor and resolve issues.

Please see the CMS/AMA document for complete details, and be sure to share this information with all your Medicare Part B providers.

Contact: Patrick Cucinelli, pcucinelli@leadingageny.org, 518-867-8827