Medicare Reminds Providers of End to ICD-10 Unspecified Codes Grace Period

In the months prior to ICD-10-CM/PCS implementation, the American Medical Association (AMA) and CMS announced guidance allowing the use of unspecified codes on certain Medicare claims.

The rule stipulated that “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 October 1, 2015.”

As defined by CMS and the AMA, “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.”

In the document released this week, CMS reaffirmed that this allowance will be coming to an end this coming October 1. In the document, CMS responded to questions from the provider community.

For example, in response to the question: “Is Medicare going to phase in the requirement to code to the highest level of specificity?” CMS reaffirmed that providers should already be coding to the highest level of specificity, and that “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.”

New Resources

In addition to affirming the end of flexibilities, CMS posted a complete list of the 2016 ICD-10-CM valid codes and code titles. The codes are listed in tabular order to reflect the ICD-10-CM code book. Also available is 2017 ICD-10-CM, the updated diagnosis code set for services provided on or after October 1, 2016.

CMS has also posted lists for transmittals that contain code updates for National Coverage Determinations (NCDs). Local Coverage Determinations (LCDs) can be found in the Medicare Coverage Database, and are searchable in a number of ways, including the “Quick Search” function on the right-hand side of the page.