Pain Management Coding Alert

Published on Tue Sep 29, 2015 PDF

Plus: The claim’s other details are just as important as the diagnosis.

As ICD-10 implementation gets underway, CMS feels optimistic about the transition, based on the latest end-to-end testing in July. According to the results CMS shared in late August, the test was an overall success.

Specifics: In the end-to-end testing week July 20-24, 2015, CMS gave providers an opportunity to submit claims with ICD-10 codes to the Medicare Fee-For-Service (FFS) claims systems and receive electronic acknowledgements confirming that their claims were accepted.

Participants: More than 1,200 testers took part, including health care providers, clearing houses, and billing agencies, representing a broad cross-section of provider, claim, and submitter types. CMS reported submission of approximately 29,286 claims.

This was the third successful ICD-10 end-to-end testing week with all Medicare Administrative Contractors (MACs) and the Durable Medical Equipment (DME) MAC Common Electronic Data Interchange (CEDI) contractor.

Results: Overall, participants in the July end-to-end testing week were able to successfully submit ICD-10 test claims and have them processed through Medicare billing systems.

Acceptance rate of the claims was 87 percent, similar to the rates in January and April, but with an increase in the number of testers and test claims submitted. Medicare accepted 25,646 of the submitted test claims. Claims with the following scenarios were rejected:

• Incorrect NPI, Health Insurance Claim Number, or Submitter ID; 
• Invalid dates of service outside the range valid for testing; 
• Invalid HCPCS codes; 
• Invalid place of service.

In addition, 1.8 percent of test claims were rejected due to invalid submission of an ICD-10 CM/PCS code. 2.6 percent of test claims were rejected due to invalid submission of an ICD-9 CM/PCS code.

“I think we are concentrating so hard to make sure we get the ICD-10 codes right that we forget to audit the claims for the everyday housekeeping that needs to be done,” says Elizabeth Earhart, CPC, a coder in Millersville, PA. “We should remember to check everything on the claim, not just the diagnosis.”

“Don’t let your other checks and balances slide just because we are switching over codes,” Earhart adds. “Use the same checklist you had for ICD-9 for ensuring a clean claim but think ICD-10 instead. Nothing is changing except those codes. Your timely filing guidelines are not changing. Your NPI is not changing. How your doctor treats is not changing. How you complete a claim is not changing.”

Plus: In many cases, testers intentionally included errors in their claims, a process often referred to as “negative testing.” These types of errors also occurred in the January and April end-to-end testing weeks. It is hoped that most rejections were the result of provider submission errors in the testing environment that would not occur when actual claims are submitted for processing.

CMS is all set: The testing also demonstrated that CMS systems are ready to accept ICD-10 claims. No new ICD-10 related issues were identified in any of the Medicare fee-for-service claims processing systems. Testing did not identify any issues with the front-end CMS systems.