There have been many headlines covering July’s joint ICD-10 announcement from the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA). In many cases, news coverage has dramatically reflected a misunderstanding of the intent of the announcement, incorrectly translating CMS’ “flexibility” regarding certain ICD-10 issues into broad overstatements about the organization’s intent to “relax” the ICD-10 deadline requirements.
The Oct 1, 2015 deadline for ICD-10 is still very much a reality. And while for the first 12 months it appears CMS will not be attempting to aggressively deny provider group’s claims for simple diagnosis-coding mistakes, they are expecting groups to be accurately and completely coding in ICD-10 at that time.
The leeway offered by CMS relates to specific situations where a valid ICD-10 code from the correct “family of codes” may have been selected, but the claim was incorrect regarding the exact level of specificity.
Here’s how it’s described on the CMS website:
While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, if a valid ICD-10 code from the right family (see question 5) is submitted, Medicare will process and not audit valid ICD-10 codes unless such codes fall into the circumstances described in more detail in Questions 6 & 7.
An example is C81 (Hodgkin’s lymphoma) – which by itself is not a valid code. Examples of valid codes within category C81 contain 5 characters, such as: C81.00 Nodular lymphocyte predominant Hodgkin lymphoma, unspecified site C81.03 Nodular lymphocyte predominant Hodgkin lymphoma, intra-abdominal lymph nodes C81.10 Nodular sclerosis classical Hodgkin lymphoma, unspecified site C81.90 Hodgkin lymphoma, unspecified, unspecified site During the 12 month after ICD-10 implementation, using any one of the valid codes for Hodgkin’s lymphoma (C81.00, C81.03, C81.10 or C81.90) would not be cause for an audit under the recently announced flexibilities.
While this flexibility will be in place for the first 12 months, medical groups still need to:
- Select valid ICD-10 codes
- Meet the detailed ICD-10 requirements around LCD/NCD rules
- Provide highly specific codes for prepayment reviews
What does this mean exactly? The bottom line is that provider groups should not slow down any of their efforts around ICD-10 readiness. While CMS is appropriately providing some flexibility around minor diagnosis mistakes, it is fully expecting that medical groups will be aggressively transitioning to the new ICD-10 standard.
We took the liberty of summarizing the July 6, 2015 CMS and the AMA joint announcement and what that means to you.
- The deadline for implementation of and transition to ICD-10 has not been extended past October 1st
- All claims with dates of service on or after October 1, 2015 must have a valid ICD-10 code or they will deny.
- A valid ICD-10 code could be three, four, five, six or seven characters.
- An ICD-10 code that is 3 characters is only valid if there are no further subdivisions of its category to include codes with four, five, six or seven characters.
- CMS will provide “audit flexibility” for 12 months following implementation and will not deny claims in a post-payment audit situation if a valid ICD-10 code is used from the correct category (family) of codes.
- LCD and NCD policies were not changed to include categories (families) of ICD-10 codes. CMS will deny claims that do not have a specific ICD-10 code consistent with LCD and NCD policies.
- CMS will require specific ICD-10 codes (not category/family codes) to be used in order to process and pay prepayment reviews.
- CMS will require specific ICD-10 codes (not category/family codes) to be used in order to process prior authorization requests.
The CMS/AMA joint announcement was good news for providers, but it was not by any means a reprieve. We suggest you maintain your focus and do all you can to make sure your ICD-10 preparedness translates directly to ICD-10 success.
Please share your thoughts about the joint announcement, and we’ll see you next time back here at RCxRules ICD-10.
