Policy & Regulation News

CMS Revises Joint Answers to ICD-10 Implementation Questions

By Jacqueline DiChiara

- ICD-10 implementation crunch time is officially here with October 1, 2015 merely a short week away. The healthcare industry nonetheless remains hungry for new coding, deadline, and claim information as the finalization of preparation efforts remains underway.

icd-10 codes

Earlier this week, The Centers for Medicare & Medicaid Services (CMS) announced a series of revisions related to its joint July announcement with the American Medical Association (AMA). CMS has reissued questions and answers, revised various question information, and has added additional information to help promote and advance ICD-10 implementation knowledge.

As RevCycleIntelligence.com reported, according to this collective ICD-10 agreement between CMS/AMA, collaborative efforts between organizations aimed to mitigate financial disruptions among healthcare providers following ICD-10 implementation. Stated this announcement, beginning on Thursday of next week, Medicare claims processing systems will no longer be able to accept ICD-9 codes for dates of services, nor will they be able to accept claims for both ICD-9 and ICD-10 codes. The joint statement additionally contained guidance allowing for greater claims auditing and quality reporting flexibility.

To help inform and educate the healthcare industry onwards before next Thursday’s ICD-10 implementation kickoff, here is an abridged summary of selected highlights from CMS’ newly revised question and answer clarification information:

How do I reach the ICD-10 Ombudsman?

As RevCycleIntelligence.com reported, CMS clarified its ICD-10 Ombudsman, William Rogers, MD, CMS’ Director of the Physicians Regulatory Issues Team, is accepting email inquiries.

(Editor's note: The contact email for Rogers was incorrectly listed in CMS's revised Q&A. CMS has since corrected this error.)

Says CMS, “The ICD-10 Ombudsman will listen to issues raised by all suppliers and providers and will evaluate any specific issues that are raised during implementation. CMS’s ICD-10 Coordination Center will be actively monitoring for any problems that may develop after October 1. This center will quickly identify and initiate resolution of issues that arise as a result of the transition to ICD-10.”

Does CMS/AMA Guidance mean another ICD-10 delay?

CMS/AMA guidance does not imply another ICD-10 implementation delay for Medicare or other organizations, says CMS. “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,” CMS confirms.

What defines a “valid” ICD-10 code?

All claims with dates of service on or after October 1, 2015 must be submitted with a valid ICD-10 code, as ICD-9 codes will no longer be accepted for these dates of service, CMS confirms, additionally noting ICD-10-CM is composed of codes with between 3 and 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,” says CMS. “A three-character code is to be used only if it is not further subdivided.”

Will I know if and when a claim is rejected?

Submitters will indeed know if a claim has been rejected if it is an invalid code as opposed to a lack of specificity associated with NCD/LCD/claim edit, says CMS. If a claim is rejected, CMS advises submitters to follow current procedure for rectifying and resubmitting rejected or denied claims and issues.

Can you define a “family of codes?”

“Family of codes” is the same as a three-character category, says CMS. “Codes within a category are clinically related and provide differences in capturing specific information on the type of condition,” CMS adds.

As per recent Guidance, will claims be rejected due to lack of specificity?

Submitted claims not recognized as a valid code will be rejected, says CMS. Physicians can resubmit claims under a valid code. A claim may be denied if the ICD-10 code lacks consistency with an applicable policy, CMS maintains.

Will NCDs/LCDs be changed to include “families of codes?

The answer is no, says CMS. “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/ 3 practitioner used a valid code from the right family of codes,” CMS confirms.

If a Medicare paid claim merges with Medicaid for a dual-eligible beneficiary, must Medicaid pay the claim?

“State Medicaid programs are required to process submitted claims that include ICD-10 codes for services furnished on or after October 1 in a timely manner. Claims processing verifies that the individual is eligible, the claimed service is covered, and that all administrative requirements for a Medicaid claim have been met,” CMS maintains. “If these tests are met, payment can be made, taking into account the amount paid or payable by Medicare. Consistent with those processes, Medicaid can deny claims based on system edits that indicate that a diagnosis code is not valid.”