A. No further implementation delays are expected. The first implementation delay moved the deadline from 2013 to 2014. Then another delay was included in the Protecting Access to Medicare Act of 2014, delaying the start until 2015. All indications point toward a final date of October 1, 2015 requiring the use of ICD-10 codes on claims submitted for reimbursement.
Q. Is the Center for Medicare & Medicaid Services confident that its systems are prepared to receive and process claims with ICD-10 codes beginning on October 1, 2015?
A. Yes. Several claim testing weeks with CMS revealed high levels of acceptance of claims (>90 percent), with only a small number of denials due to an invalid ICD-10 code. CMS encouraged testing with clearinghouses and others to ensure a smooth transition.
Q. Will CMS provide any latitude with code selection due to the newness of these codes?
A. In a July FAQ, CMS published information about a one-year grace period associated with code selection. It stated:
While diagnosis coding to the correct level of specificity is the goal for all claims, 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.
CMS clarified that family of codes means “category,” which is the first three digits of an ICD-10 code. CMS further clarified that the grace period is associated with a claim review and not with an initial claim submission.
Q. Will CMS penalize physicians who apply incorrect ICD-10 codes as they relate to the quality reporting programs?
A. CMS addressed this concern in its FAQ publication:
For all quality reporting completed for program year 2015 Medicare clinical quality data review contractors will not subject physicians or other Eligible Professionals (EP) to the Physician Quality Reporting System (PQRS), Value Based Modifier (VBM), or Meaningful Use 2 (MU) penalty during primary source verification or auditing related to the additional specificity of the ICD-10 diagnosis code, as long as the physician/EP used a code from the correct family of codes. Furthermore, an EP will not be subjected to a penalty if CMS experiences difficulty calculating the quality scores for PQRS, VBM, or MU due to the transition to ICD-10 codes. CMS will not deny any informal review request based on 2015 quality measures if it is found that the EP submitted the requisite number/type of measures and appropriate domains on the specified number/percentage of patients, and the EP’s only error(s) is/are related to the specificity of the ICD-10 diagnosis code (as long as the physician/EP used a code from the correct family of codes).
In the subsequent clarification, CMS indicated that leniency will apply in the event of failure with the quality program and a subsequent appeal revealing that the failure was due to diagnosis codes.
Q. Will CMS continue to update ICD-10 files on its website?
A. Yes. The 2016 General Equivalence Mapping (GEM) files are currently available on the CMS website at cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html. In addition, the 2016 ICD-10 files are also posted on the CMS website.
Q. Some ophthalmic conditions that are coded per eye did not have a laterality designation in the 2015 ICD-10 manual. Will these change in 2016?
A. Unfortunately, no. Based on the files published on the CMS website, there continues to be no laterality designation for primary open-angle glaucoma (H40.11x-); age-related macular degeneration (H35.31 – dry), (H35.32 – wet); and diabetes with ophthalmic manifestations (E1-.---). Additional examples may exist.
Q. Will practices still relying on superbills or route slips be able to continue to use them after October 1, 2015?
Practices may continue to create superbills that contain the most common diagnosis codes used in their practice. ICD-10-CM-based super bills will not necessarily be longer or more complex than ICD-9-CM-based superbills. Neither currently used superbills nor ICD-10-CM-based superbills provide all possible code options for many conditions.
Practices should be able to cull their existing superbill down to the most commonly used codes to create one containing ICD-10 codes should they choose to continue to use a superbill.
Q. Will CMS require the use of “external causes” codes on claims (e.g., V86.59xA – Driver of golf cart injured in non-traffic accident)?
A. No. The CMS Medicare Learning Network (MLN Matters) article number SE1518 states the following:
Similar to ICD-9-CM, there is no national requirement for mandatory ICD-10-CM external cause code reporting. Unless you are subject to a State-based external cause code reporting mandate or these codes are required by a particular payer, you are not required to report ICD-10-CM codes found in Chapter 20 of the ICD-10-CM, External Causes of Morbidity. If you have not been reporting ICD-9-CM external cause codes, you will not be required to report ICD-10-CM codes found in Chapter 20 unless a new State or payer-based requirement about the reporting of these codes is instituted. If such a requirement is instituted, it would be independent of ICD-10-CM implementation. In the absence of a mandatory reporting requirement, you are encouraged to voluntarily report external cause codes, as they provide valuable data for injury research and evaluation of injury prevention strategie
For example, CMS would accept the code for traumatic hyphema (S05.1- - -) and, although they exist, would not require submission of these additional codes on the claim:
V86.59xA–Driver of golf cart injured in non-traffic accident;
W21.04xA–Struck by golf ball;
Y92.39–Golf course as place of occurrence;
Q. What other concessions is CMS making related to the implementation of ICD-10?
A. CMS has plans in place to assist with implementation in a few additional ways:
1. CMS will establish an ICD-10 ombudsman to receive and triage physician and provider issues;
2. CMS will authorize advance payments if Medicare Administrative Contractors (MACs) are unable to process claims within established time limits due to ICD-10 issues. REVIEW
Ms. McCune is vice president of the Corcoran Consulting Group. Contact her at DMcCune@corcoranccg.com.