ICD-10
The American Medical Association and Centers for Medicare and
Medicaid Services (CMS) jointly announced that agreement had been
reached on important elements of a "grace period" for the October 1,
2015, implementation of the ICD-10 diagnosis code set.
• For a one year period starting October 1, Medicare claims will not be
denied solely on the specificity of the ICD-10 diagnosis codes
provided, as long as the physician submitted an ICD-10 code from an
appropriate family of codes.
• In addition, Medicare claims will not be audited based on the
specificity of the diagnosis codes as long as they are from the
appropriate family of codes. This policy will be followed by Medicare
Administrative Contractors and Recovery Audit Contractors.
• To avoid potential problems with mid-year coding changes in CMS
quality programs (PQRS, VBM and MU) for the 2015 reporting year,
physicians using the appropriate family of diagnosis codes will not be
penalized if CMS experiences difficulties in accurately calculating
quality scores (i.e., for PQRS, VBM, or Meaningful Use).
• CMS will continue to monitor implementation and adjust the duration
if needed.
CMS will establish an ICD-10 Ombudsman to help receive and triage
physician and provider problems that need to be resolved during the
transition.
CMS will authorize advanced payments if Medicare contractors are
unable to process claims within established time limits due to problems
with ICD-10 implementation.
Family of Codes
• With regard to the issue of “Family of Codes” mentioned in the
previous slides, CMS has instructed the MACs to not deny claims for
doctors who use an ICD-10 code that’s not quite as specific as it could
be, as long as the codes are in the right ICD-10 family.
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• If you don't quite “nail” a code to the most exact level, supposedly,
you will not have your Medicare claims denied during that period.
• Note: They may, of course, deny based on normal NCD or LCD policy
directives as to Covered Indications for a given service.
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What does “ICD-10 family” mean?
• In CMS’s view, a “family of codes” is the ICD-10 three-character
category number, such as H25 (Age-related cataract).
• Codes within a three-character category are clinically related; they
reflect different, detailed information on the type of condition.
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• When you look at the Tabular List you’ll see that within the H25
category are a number of specific codes that reflect different, detailed
information, regarding the type of cataract it is and which eye is
involved.
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There are:
• H25.031 (Anterior subcapsular polar age-related cataract, right eye),
which has six characters;
• H25.22 (Age-related cataract, morgagnian type, left eye), which has
five characters;
• H25.9 (Unspecified age-related cataract), which has four characters –
and others.
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Note: Some codes have six characters, some five, some four and so
on. There do exist some valid codes that have only three characters,
but in many instances, the code will require more than three characters
in order to be valid.
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• Important note: Do not just report a category number, such as H25.
• Instead, you need to report one of the valid codes that you’ll see in
the Tabular List, dependent, of course, on the patient’s condition.
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In summary, if you haven’t quite chosen the exactly right code, that
should be sufficient as long as:
(1) you have the right three-character category number AND
(2) you have reported some valid code within that category.
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