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CMS Releases Q&A Guidance on ICD-10 Flexibilities

July 28, 2015
by Rajiv Leventhal
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The Centers for Medicare & Medicaid Services (CMS) has provided more clarification related to its July 6 joint announcement with the American Medical Association (AMA) regarding ICD-10 flexibilities.

Earlier this month, CMS announced a joint effort with AMA to help physicians get ready ahead of the Oct. 1 deadline to transition to the ICD-10 coding set. In a recent Q&A about these flexibilities, posted by CMS, the agency said, “The CMS/AMA Guidance does not mean there is a delay in the implementation of the ICD-10 code set requirement for Medicare or any other organization.  Medicare claims with a date of service on or after October 1, 2015, will be rejected if they do not contain a valid ICD-10 code.  The Medicare claims processing systems do not have the capability to accept ICD-9 codes for dates of service after September 30, 2015 or accept claims that contain both ICD-9 and ICD-10 codes for any dates of service. Submitters should follow existing procedures for correcting and resubmitting rejected claims.”

Regarding what constitutes a valid ICD-10 code, CMS said, “ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity. A three-character code is to be used only if it is not further subdivided. To be valid, a code must be coded to the full number of characters required for that code, including the 7th character, if applicable. Many people use the term billable codes to mean valid codes.”

What’s more, during the July 6 announcement, CMS said that for the first 12 months post-transition, it will not deny or audit physician or other practitioner claims solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family. In the recent Q&A, the agency clarified, ‘Family of codes’ is the same as the ICD-10 three-character category.  Codes within a category are clinically related and provide differences in capturing specific information on the type of condition.”

The agency continued, “As stated in the CMS’ Guidance, 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 of codes.” CMS did say, however, that he recent Guidance does not change the coding specificity required by the national coverage determinations (NCDs) and local coverage determinations (LCDs). “Coverage policies that currently require a specific diagnosis under ICD-9 will continue to require a specific diagnosis under ICD-10,” it said.

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