CMS Answers ICD-10 FAQs for Healthcare Providers
By Sara Heath
ICD-10 implementation will begin on October 1, 2015, and as such, the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) announced that, in order to ease the transition, they will be flexible when filing claims that do not use specific enough codes. On July 27, the organizations released a frequently asked questions list regarding the guidance.
The primary concerns addressed in the FAQ were the implementation date of ICD-10 and specificity of the coding required for filing claims under ICD-10. CMS sought to clarify any implementation date questions as well as to give a brief overview of the coding process for ICD-10 and to describe which codes will and will not be accepted following the October 1 start date.
To the question, “Does the Guidance mean there is a delay in ICD-10 implementation?” CMS responded by saying that the implementation date was going to remain October 1. The FAQ clarified that CMS’s computing systems aren’t capable of processing claims dated after September 30 that use ICD-9 codes, and that it was imperative that the transition be made by that date. Claims dated after September 30 that use ICD-9 codes will be denied.
CMS continues by discussing how ICD-10 codes are composed, answering questions about what makes a valid code. ICD-10 codes are composed of 3, 4, 5, 6, or 7 characters, and codes with more characters are more specific. Three-character codes are category numbers, or family codes, and correlate to a broad diagnosis. Each subsequently added character makes that diagnosis increasingly specific.
CMS explains an example of how this will work. A three-character code, E10, will be for a general diagnosis, type 1 diabetes mellitus. There will also be codes within that category, like E10.21, which would correlate to type 1 diabetes mellitus with diabetic nephropathy. The two additional characters were able to communicate specifically what diagnosis the patient had.
The document also answers questions about denied claims under ICD-10, such as if one will know if a claim was denied due to an invalid code or a lack of specificity (the answer is yes), or if the guidance applies to National Coverage Determination (NCD) or Local Coverage Determination (LCD) claims. CMS says that for NCD and LCD claims, one must follow those specific protocols for specificity. For all Medicare fee-for-service claims, the guidance does apply. This means that claims that are not specific enough will not be denied so long as they are submitted with an actual code and not just a category number.
CMS continues by answering questions regarding which plans are covered by this ICD-10 flexibility, and stating that only Medicare fee-for-service claims can benefit from this flexibility. Programs that are not included in the ICD-10 flexibility are NCD and LCD claims that require certain specificity, ICD-10 audit and quality program flexibilities, and any commercial payers a healthcare provider may file claims with.
The CMS flexibility is a policy that states that Medicare will not be denying claims due to lack of specificity in coding so long as the code is from the correct family code. This period of flexibility will end 12 months after the implementation of ICD-10.
