Recently, the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) made a joint announcement regarding new steps intended to help ease the ICD-10 transition for physicians. CMS and AMA were careful NOT to call this a “grace period” and CMS has reiterated that ICD-10 transition will move forward on October 1, 2015.

Auditing Flexibility 

CMS said that for the 12 months after ICD-10 implementation, claims auditors will not deny inaccurate Medicare claims solely on the basis of lack of specificity if providers use a valid ICD-10 code from the correct “family” of codes. However, a valid ICD-10 code will still be required on all claims starting on October 1. Therefore, this is neither a delay of ICD-10, nor even a “grace period” in the sense of the AMA’s earlier proposal to allow for dual coding ICD-9 and ICD-10; rather, the announced flexibility relates only to the claims auditing and quality reporting programs.

Specifically, the flexibility announced by CMS and the AMA simply provides some relief from auditing denials, as long as the code used is in the correct “family” of ICD-10 codes. Importantly, all claims submitted with ICD-9 codes after October 1 will be denied. CMS also may deny payment of claims for other reasons related and unrelated to ICD-10 codes. Finally, this policy applies only to Medicare, not private insurers who are still free to deny ICD-10 claims based on a lack of specificity.

Quality Reporting Flexibility

CMS has indicated that if a less specific ICD-10 code is used for a quality reporting program (Meaningful Use, PQRS) during the 2015 performance period, CMS will not subject physicians to penalties based on the specificity of diagnosis codes, as long the code is from the correct “family.” This does not mean that there will be no penalties for failure to report using ICD-10 codes or failure to report at all. Those penalties are still in place. This is a very limited case involving only the use of more generic codes from the correct family of ICD-10 codes and not the desired, more specific codes they expect should be used.

Provisions Related to Medicare Contractors

CMS states it will authorize advance payments to physicians in the event that Medicare contractors are unable to process claims with ICD-10 codes due to technical issues on their part.                

Impact on healthcare providers and organizations

The additional support announced by CMS and the AMA is very limited in scope and impact. The flexibility CMS has granted doesn’t change the fact that providers must look up or pick appropriate ICD-10 codes for billing. The fact that CMS plans to allow less specific codes may actually afford no flexibility at all in many instances where the higher level “NOS” code is already most appropriate. CMS plans to issue guidance in the future as to what they mean by the correct “family” of codes and if that would include failure to select the correct code for whether an event was initial, subsequent, or sequelae.

NextGen Healthcare strongly urges everyone to stay on track and to take advantage of any and all available resources to assist in meeting the October 1 deadline. We are dedicated to ensuring your practice is ready to answer the ICD-10 bell in the fall of 2015. The ICD-9/ICD-10 Comparison Utility3M ICD-10 Online Education Program, and, for NextGen Healthcare clients, our ICD-10 Readiness resources are examples of multiple resources ready for you now.

Also, free help from CMS includes an FAQ and “Road to 10,” a site aimed specifically at smaller physician practices. That site includes primers for clinical documentation, clinical scenarios, and other specialty-specific resources to help with implementation. CMS has also released provider training videos that offer helpful ICD-10 implementation tips.