CMS Prepares Providers for End of ICD-10 Coding Flexibilities

August 22, 2016 - Starting on October 1, CMS plans to thaw the freeze on ICD-10 implementation by adding more codes and allowing review contractors to deny claims based on level of specificity. To help healthcare providers prepare for updates to ICD-10 coding rules, CMS recently released several clarifying responses to commonly asked questions regarding the upcoming changes.

In the updated FAQ page, CMS reconfirmed that ICD-10 flexibilities will end on October 1, indicating that providers will no longer be able to use unspecified or less specific codes if there is a more appropriate code for the healthcare encounter. Providers risk receiving a claim denial if a review contractor finds that a more specific code was applicable.

When CMS first implemented ICD-10, it allowed providers to submit a valid code from the correct diagnostic family, or ICD-10 three-character category, even if a more specific code existed. Review contractors could not deny Medicare fee-for-service claims based of specificity issues with diagnosis codes. However, CMS only scheduled the flexibilities to last for 12 months after ICD-10 implementation to help providers adjust to the new system.

“ICD-10 flexibilities were solely for the purpose of contractors performing medical review so that they would not deny claims solely for the specificity of the ICD-10 code as long as there is no evidence of fraud,” CMS stated. “These ICD-10 medical review flexibilities will end on October 1, 2016. As of October 1, 2016, providers will be required to code to accurately reflect the clinical documentation in as much specificity as possible, as per the required coding guidelines.”

CMS noted that many providers may already be using specific ICD-10 codes because many major private payers opted out of flexibility rules after ICD-10 implementation.

While providers must ensure that codes are as specific as possible to avoid claims denials, CMS also clarified that unspecified codes can still be used in certain situations after ICD-10 flexibilities expire. The federal agency reported that unspecified codes have “acceptable, even necessary, uses.”

“While you should report specific diagnosis codes when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, in some instances signs/symptoms or unspecified codes are the best choice to accurately reflect the health care encounter,” wrote CMS. “You should code each health care encounter to the level of certainty known for that encounter.”

Providers can appropriately use unspecified codes after October 1 if clinical information is absent to support the diagnosis of a certain health condition with a more specific code. For example, if a provider determines a patient has pneumonia, but the type was not diagnosed in the healthcare encounter, then it is acceptable to use a valid unspecific code.

To prevent claim denials following the updates, CMS advised providers to look over the 2016 and 2017 ICD-10 valid codes and code titles lists that are posted on the federal agency’s website. Providers should familiarize themselves with updated diagnosis code sets.

CMS also recommended that providers “avoid unspecified ICD-10 codes whenever documentation supports a more detailed code” and “check the coding on each claim to make sure that it aligns with the clinical documentation.”

In addition, providers should identify which codes impact their practices and concentrate on clinical concepts behind new codes.

Despite several updates to ICD-10 coding rules, some providers may not need to worry about the addition of ICD-10 codes. Approximately 97 percent of new codes are related to the cardiovascular system and 84 percent of the updated codes do not impact existing national coverage determinations.

However, CMS stated that national and local coverage determinations will be updated as new codes are added. Codes that affect national coverage determination will be added as soon as possible after the updated codes are finalized.

The federal agency also attempted to reassure providers that it is prepared to manage the addition of new ICD-10 codes and rules. In the final FAQ, CMS stated that it does not expect any delays to updating the system and it is “well equipped to handle changes to codes and to processes.”

Dig Deeper:

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