General Surgery Coding Alert

Get to the right code family.

You won’t be able to keep using ICD-9 beginning October 1, but at least the pressure is off for losing pay if you make some ICD-10 mistakes right out of the blocks.

That’s because CMS has stated that if you can at least list an ICD-10 code from the right “family,” your Medicare administrative contractor (MAC) will pay your claims for the first calendar year following the Oct. 1, 2015 implementation date.

In a compromise hammered out between the AMA — which wanted to delay ICD-10 implementation — and CMS — which insisted that the show must go on — the two agencies are partnering to provide resources to the healthcare community, and also making compromises about claims acceptance that will please everyone.

The deal: CMS and the AMA recently announced that they’ve forged a partnership to help practices during the final three months before ICD-10 implementation in response to urging from the provider community. As a result, the two groups released guidance that included four points to ease your code-set transition.

Compromise 1: Incorrect ICD-10 codes won’t automatically trigger denials. If you use the wrong ICD-10 code within the first year after October 1, your MAC will still process and pay your claim will, as long as you use an ICD-10 code from the correct code group, CMS says.

“While diagnosis coding to the correct level of specificity is the goal for all claims, 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 … based solely on the specificity of the ICD-10 diagnosis code, as long as the physician/practitioner uses a valid code from the right family,” CMS says in the guidance.

Keep in mind, however, that this doesn’t let you off the hook completely — you still have to use a valid ICD-10 code on your claim and it has to be from the correct code family. In addition, your claim could still be denied for other reasons besides the ICD-10 code’s specificity.

Compromise 2: If you use the wrong ICD-10 code for quality reporting, you won’t face penalties. Whether you’re reporting for PQRS, value-based modifiers (VBM), or meaningful use (MU), no penalties will apply as long as you use an ICD-10 code from the right code family.

“An eligible professional (EP) will not be subjected to a penalty if CMS experiences difficulty calculating the quality scores for PQRS, VBM, or MU due to the transition to ICD-10 codes,” CMS added.

Compromise 3: You could be entitled to an advance payment if your MAC faces “administrative problems.” If your MAC experiences a system malfunction or has trouble implementing ICD-10, you might be able to collect a conditional partial payment until the issues are resolved.

The advance payments — which require repayment — do not apply if the physician is unable to submit a valid claim for services rendered, CMS clarifies. However, if a Medicare systems issue interferes with claims processing, CMS and the MACs will post information on how you can request an advance payment.

Compromise 4: You’ll have access to an ombudsman and a communications center to answer your questions. CMS is anticipating issues and questions during the ICD-10 transition, and is therefore creating a “communication and collaboration center” as well as appointing an ICD-10 ombudsman to resolve issues and address concerns. “As we get closer to the Oct. 1, 2015 compliance date, CMS will issue guidance about how to submit issues to the Ombudsman,” CMS said in the guidance.

CMS, AMA Smooth Transition

Although the four new ICD-10 allowances may not address all of your concerns about the transition, they should certainly help surgery practices feel better about the approaching implementation date.

“We appreciate that CMS is adopting policies to ease the transition to ICD-10 in response to physicians’ concerns that inadvertent coding errors or system glitches during the transition to ICD-10 may result in audits, claims denials, and penalties under various Medicare reporting programs,” said Steven J. Stack, MD, president of the AMA, in a July 6 statement. “We will continue to work with the administration in the weeks and months ahead to make sure the transition is as smooth as possible.”

Resource: To read the CMS/AMA guidance, visit www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10-guidance.pdf.