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Breaking News: ICD-10 Errors

CMS: Contractors 'will not deny' claims with certain ICD-10 errors for one year.

Practices will have one more year after ICD-10 implementation October 1, 2015, to get their diagnosis coding exactly right as CMS and the AMA announced July 6, 2015, that a lack of code specificity will not cause claims denials for Part B providers.

Medicare administrative contractors (MACs) and recovery auditors (RACs) will be instructed not to deny claims "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/practitioner used a valid code from the right family," according to frequently asked questions (FAQs) that accompany the announcement.

CMS and AMA stress that ICD-10 codes will still be required starting October 1, 2015.

The idea of a grace period had been backed by several major players in the national health care debate, including the AMA House of Delegates, which passed a resolution June 8 to push for a two-year ICD-10 grace period. In the U.S. Congress, several bills calling for a grace period have been introduced, most recently H.R. 2652, the Protecting Patients and Physicians Against Coding Act of 2015, submitted by Rep. Gary Palmer, R-Ala., on June 4, 2015.

The leniency also applies to the Physician Quality Reporting System (PQRS), value-based modifier and meaningful use stage 2. Contractors will not assess penalties based on ICD-10 code use in reporting, nor will they deny eligible providers' (EPs') informal review requests, so long as "a valid code from the right family" is used, the right number and type of measures in appropriate domains have been submitted for the specified number/percentage of patients and the errors are related only to the specificity of the ICD-10 diagnosis code, according to the FAQs.

If Medicare contractors have trouble processing claims as a result of ICD-10 issues, "an advance payment may be available" if the claim is otherwise valid, pending submission of a request by the provider to the appropriate MAC. The usual conditions, described in 42 CFR Section 421.214, must be met.

CMS says it will set up "a communication and collaboration center" with an "ICD-10 ombudsman to help receive and triage physician and provider issues" and promises further guidance on these issues closer to October 1, 2015, including a National Provider Call scheduled for August 27, 2015.

The CMS FAQ may be found here:
https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10-guidance.pdf. AMA President Steven J. Stack's editorial can be found here: http://www.ama-assn.org/ama/ama-wire/post/cms-icd-10-transition-less-disruptive-physicians.

Look for continuing coverage of this and all ICD-10 developments in future issues of Part B News, Medical Practice Compliance Alert, Medical Practice Coding Pro and Pink Sheets for anesthesia and pain, cardiology and orthopedics.

This content was republished with permission from DecisionHealth and Part B News. To start a free trial or subscribe, please visit www.partbnews.com.
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