CMS Clarifies ICD-10 Flexibility Guidelines

The Centers for Medicare and Medicaid Services (CMS) on Tuesday released clarifications to the guidance it released earlier this month with the American Medical Association on easing the transition from ICD-9 to ICD-10. The guidance, released in early July, was issued in response to physician concerns about the claims auditing and quality reporting processes associated with the transition.

The frequently asked questions (FAQ) document released this week further explains flexibility measures such as the implementation of an ICD-10 ombudsman, what constitutes a valid ICD-10 code, and courses of action providers can take when a claim is denied.

One of the guidelines providers questioned after the release of the original CMS/AMA guidance is an item that stated: “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/practitioner used a valid code from the right family. However, a valid ICD-10 code will be required on all claims starting on Oct. 1, 2015.”

The FAQ clarifies what CMS considers to be a “valid ICD-10 code” as:

To be valid, a code must be coded to the full number of characters required for that code, including the 7th character, if applicable. Many people use the term billable codes to mean valid codes. For example, E10 (Type 1 diabetes mellitus), is a category title that includes a number of specific ICD-10-CM codes for type 1 diabetes. Examples of valid codes within category E10 include E10.21 (Type 1 diabetes mellitus with diabetic nephropathy) which contains five characters and code E10.9 (Type 1 diabetes mellitus without complications) which contains four characters.

Another point of confusion in the initial CMS/AMA document was how it defined “a family of codes,” which some providers perceived as imprecise. The CMS response was:

“Family of codes” is the same as the ICD-10 three-character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. For instance, category H25 (Age

-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved…One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid.

Another question CMS clarified was “Will the commercial payers observe the one-year period of claims payment review leniency for ICD-10 codes that are from the appropriate family of codes?”

Their response is:

The official Guidance only applies to Medicare fee-for-service claims from physician or other practitioner claims billed under the Medicare Fee-for-Service Part B physician fee schedule.Each commercial payer will have to determine whether it will offer similar audit flexibilities.

Click here to read the full FAQ from CMS.

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