Inpatient Facility Coding & Compliance Alert

CMS and AMA promise 4 concessions to ease the transition.

Breathe easy, for CMS and the AMA have come forward with four surprise concessions to help providers in their seamless transition to ICD-10 coding. In a press release on July 6, CMS also released additional guidance to help providers get ready for the Oct. 1 deadline. These concessions shall apply for 12 months after the implementation of the ICD-10 CM/PCS.

On July 27, CMS further released a clarification sheet to answer provider questions on ICD-10 flexibilities.

“Many providers are still in denial about ICD-10 actually implementing so this would help those doctors play catch up,” says Elizabeth Earhart, CPC, a coder in Millersville, PA. CMS states that all services paid under the Medicare Fee-for-Service Part B physician fee schedule are covered by the guidance. Here is a low down on what’s in store for you.

No Denials Based on ICD-10 Mistakes In Claims

To put an end to the major issue of which providers were apprehensive, CMS assures that it will reimburse for wrongly coded claims, as long as you at least attempt to use a valid code from the same broad family.

Claim denials: The CMS official guidance document says that, “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 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.”

Clarification: What makes a valid code? We all know that ICD-10-CM is composed of codes with 3, 4, 5, 6, or 7 characters. “Family of codes” is the same as the ICD-10 three-character category. 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. CMS explains that, “To be valid, a code must be coded to the full number of characters required for that code, including the 7th character, if applicable.

For example: E10 (Type 1 diabetes mellitus) is a category title that includes a number of specific ICD–10-CM codes for type 1 diabetes. Examples of valid codes within category E10 include E10.21 (Type 1 diabetes mellitus with diabetic nephropathy) which contains five characters and code E10.9 (Type 1 diabetes mellitus without complications) which contains four characters.

CMS Supports Your Quality Reporting, Too

If you were worried that your quality reporting would be affected because of the increased sophistication in levels required with the ICD-10 codes, CMS has thought of an answer. The official guidance document declares that, “For all quality reporting completed for program year 2015 Medicare clinical quality data review contractors will not subject physicians or other Eligible Professionals (EP) 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.”

What’s more, if there are difficulties in calculating the quality scores for PQRS, VBM, or MU due to the transition to ICD-10 codes, CMS will not subject the EP to any penalty whatsoever.

However, you need to take care so as to submit the requisite number/type of measures and appropriate domains on the specified number/percentage of patients. CMS will continue to monitor the implementation and adjust the timeframe if needed.

“My concern is that providers who haven’t started the transition will use this a crutch till the end of the year,” contemplates Earhart.

Get Advance Payments When MACs Delay Claim Processing

CMS says, “When the Part B Medicare Contractors are unable to process claims within established time limits because of administrative problems, such as contractor system malfunction or implementation problems, an advance payment may be available.”

This advance payment would be a conditional partial payment, which would require repayment, and would be issued condition to the CMS regulations at 42 CFR Section 421.214. If you wish to apply for an advance payment, then submit your request to the appropriate Medicare Administrative Contractor (MAC). In case there are issues that delay the claims process, CMS and the MACs will post information on how to access advance payments.

“There are so many checks and balances when doing claims that it’s difficult to think we would take advantage of this,” feels Earhart. “I am assuming the MACs would alert us of a delay and then we could claim.”

Let the ICD-10 Ombudsman Assist You

The CMS has been thoughtful enough to create a communication center, an ICD-10 Ombudsman, “to help receive and triage physician and provider issues.” The Ombudsman will work closely with representatives in CMS’s regional offices to address physicians’ concerns.

The center will also “identify and initiate “resolution of issues caused by the new code sets as well. Very soon, CMS plans to issue guidance about how to submit issues to the Ombudsman.

Clarification: The Ombudsman will be in place by Oct. 1, 2015.

Miles to Go Before You Sleep

Yes, all this does seem quite soothing to the nerves. However, the fact remains that you still have to prepare for the big change. A valid ICD-10 code will be required on all claims starting on Oct. 1, 2015.

CMS says in the clarification note, “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.”

Clarification on NCDs and LCDs: Note that the recent guidance does not change the coding specificity required by the NCDs and LCDs. A specific diagnosis under ICD -9 will continue to require a specific diagnosis under ICD-10. However, that should not be a problem because they require no greater specificity in ICD-10 than was required in ICD-9, with the exception of laterality, which does not exist in ICD-9.

Audits are always possible: Do not put your audit readiness efforts on the backburner. According to CMS, even though it has to concede to omit the ICD-10 errors during the transition period, there can always be reasons other than the specificity of the ICD-10 code that can warrant a claim to be chosen for review.

Medicare fee-for-service prior authorization requests: The flexibility extends to only the post-payment reviews. The Medicare Administrative Contractors, the Recovery Audit Contractors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractors would not touch you regarding the ICD-10 coding errors, but would be ready with a microscope when it comes to your conformance with the regular standards. Moreover, when it comes to prepayment reviews and prior authorization requests, you would still require ICD-10 codes with the correct level of specificity.

In the words of Earhart, “It’s better to be over prepared than not prepared at all. There’s no excuse not to know the guidelines, dates, or codes by October 1.” So, prepare with full stead, now that CMS has taken half the burden off your wings.

For more information you may visit:

https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10-guidance.pdf

http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-07-06.html

http://www.cms.gov/Medicare/Coding/ICD10/Clarifying-Questions-and-Answers-Related-to-the-July-6-2015-CMS-AMA-Joint-Announcement.pdf