ICD 10 Grace Period – Are You Interpreting It Correctly?

Written on August 10, 2015

On July 6, 2015, the Center for Medicare and Medicaid Services announced efforts to ease the transition to ICD 10 by issuing a one year grace period on ICD 10 specificity. Some members of Congress argued for dual coding of ICD 9 and ICD 10 for one year but CMS opted for ICD 10 coding only to begin October 1. The CMS statement says a Medicare review contractor will not deny physician or other practitioner claims billed under the Part B physician fee schedule through automated review or complex medical review based solely on the specificity of the ICD 10 diagnosis code as long as the physician /practitioner has used a valid code from the right family. The word “family” is unclear and is not an appropriate term for ICD codes. The preferred nomenclature is “category” or “subcategory.” The CMS reference appears to mean three digit code category (Example: M16 is the heading for all codes related to the osteoarthritis of the hip). Physicians must still understand ICD 10 and the documentation must still support the diagnosis and service. No other carriers have stated they will follow the same criteria. Many commercial carriers have payment policies related to specific services and require a specific diagnosis for payment of the service. The announcement also stated penalties would not be given related to PQRS, Value Based Modifier or Meaningful Use based on lack of coding specificity as long as the data contained codes from the right family. According to the American Medical Association, if Medicare contractors are unable to process claims due to problems with ICD 10, CMS will authorize advance payments to physicians. CMS will also establish a communication center to resolve issues as quickly as possible. It is important that physicians and practices do not see this grace period and support structure as a reason to halt preparation. Physicians should be working to improve documentation and coders should be auditing the documentation and offering feedback for improvement. All processes and forms should be scrutinized due to the fact that charge capture, pre-certification, referral and ordering will be affected by the change. Physicians are responsible for claims submitted to carriers in their name related to accuracy and level of service. It is important that physicians begin to take responsibility for assuring the level of service and the diagnosis is correct and supported through accurate documentation. This article was featured in the Summer 2015 issue of Warren Averett’s Health Care Headlines.

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