AMA/CMS ICD-10 update

CMS and the AMA announced an update that will allow providers to get help with the transition, as well as some relief from potential claim denials. https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10-guidance.pdf

According to CMS guidance issued July 6, for the first year that ICD-10 is in place, Medicare Administrative Contractors (MACs) will not deny Part B claims on the specificity of the ICD-10 diagnosis code as long as it is valid.

Claims denials

CMS said that for the first year after ICD-10 implementation, Medicare review contractors won’t deny eligible professional Part B claims based solely on the specificity of the ICD-10 diagnosis code, though contractors could choose a claim for review for other reasons. You still must report a “valid code from the right family,” though. CMS said that Medicare Administrative Contractors, the Recovery Audit Contractors, Zone Program Integrity Contractors, and Supplemental Medical Review Contractors will follow this policy.

Quality reporting and other penalties

CMS said also that 2015 quality reporting programs would not penalize physicians for insufficient specificity related to ICD-10 coding. “For all quality reporting completed for program year 2015, Medicare clinical quality data review contractors will not subject physicians or other Eligible Professionals (EPs) to the Physician Quality Reporting System (PQRS), Value Based Modifier (VBM), or Meaningful Use 2 (MU) penalty during primary source verification or auditing related to the additional specificity of the ICD-10 diagnosis code, as long as the physician/EP used a code from the correct family of codes,” the CMS guidance report stated.

CMS added that EPs won’t face a penalty if CMS has trouble calculating quality scores for PQRS, VBM, or MU2 due to the ICD-10 transition period.

Help for payment disruptions

If Medicare contractors are unable to process claims because of problems with ICD-10, CMS will authorize advance payments to physicians. CMS said that such problems could include contractor system malfunctions or implementation issues, and that an advance payment would be a conditional partial payment that would require repayment. CMS said that it did not have authority to make advance payments in cases where physicians could not submit a valid claim for services rendered.

Ombudsman for ICD-10 implementation

A “communication and collaboration center for monitoring the implementation of ICD-10” will be set up to quickly identify and resolve issues related to the transition. This center will include an ICD-10 Ombudsman to help receive and triage provider issues, working closely with representatives in CMS regional offices.

Reliable Billing has been trained by the American Academy of Professional Coders (AAPC) on ICD-10 as part of our certification and understand the guideline requirements. Our billing system has been updated to accommodate the new codes to ensure no lag time October 1st. If you feel unprepared, we are here to help but highly recommend an online or seminar course with AAPC. www.aapc.com