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CMS Clarifies ICD-10 Flexibility Guidance

On July 6, 2015, CMS published guidance granting some flexibility associated with the October 1, 2015 implementation of ICD-10. They indicated the following:

  • One year grace period with no denials based on specificity as long as ICD-10 code is from appropriate family of codes
  • No penalty with quality programs (PQRS, VBM, MU) as long as appropriate family of codes is used
  • CMS to establish ICD-10 Ombudsman to receive and triage physician and provider issues
  • CMS to authorize advanced payments if MACs are unable to process claims within established time limits due to ICD-10 issues

The full document can be found at: http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10-guidance.pdf.

Although it is helpful, this guidance generated several questions which CMS addresses in another guidance document published July 27, 2015.

Of particular concern was the definition of “family of codes”. Interestingly, CMS used age-related cataract as the example to define “family of codes”. They indicate that “family of codes” is the same as the ICD-10 three character category. H25 is the category for age-related cataract. If you file a claim for a cataract patient with something from this category, you would meet their definition of having used the appropriate family of codes as long as the patient has a form of age-related cataract. IMPORTANT: The code must still be a valid code so most submissions will require more than three characters to be valid.

CAVEAT: Because many contractors have already developed local coverage decisions (LCDs) with valid ICD-10 codes for specific services, the concept of “family of codes” will not always apply. When there is a specific LCD, the only codes that will pass through the edit are those in the LCD.

The applicability of “family of codes” and the one-year grace period applies to those claims under review either through automated or complex medical record review or those appealing an unfavorable outcome to a quality program.

In addition, the clarification guidance stipulates that the grace period and other flexible rules apply only to claims paid under the Medicare Part B payment system and not Medicaid. Commercial payers may or may not choose to provide similar guidance.

The full clarification document can be found at: https://www.cms.gov/Medicare/Coding/ICD10/Clarifying-Questions-and-Answers-Related-to-the-July-6-2015-CMS-AMA-Joint-Announcement.pdf.

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