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Ready or not ICD-10 is here


Like many practices, yours may be facing lost productivity as a result of the learning curve or lack of preparedness for the conversion to ICD-10. Claim rejections or delays in payment in some cases may jeopardize healthy cash flow during these first few months.

This flexibility extends to penalties related to the Physician Quality Reporting System (PQRS), the Value-Based Modifier (VBM) or the Meaningful Use (MU) program.The good news is that Medicare fee-for-service Part B claims will be processed and not audited through Sept. 30, 2016. Medicare will accept unspecified codes for this one-year grace period. The one-year transition period brokered by the American Medical Association with the Centers for Medicare & Medicaid Services (CMS) should help to mitigate potential problems arising from coding errors related to granularity or system glitches.

The bad news is that the grace period is for traditional Medicare claims only. It does not extend to Medicaid, Medicare Advantage or other claims.

Speaking at a webinar sponsored by ZirMed, Inc., a cloud-based financial and clinical performance management company, Elizabeth Woodcock, MBA, FACMPE, CPC, noted that practices with a lot of evaluation and management (E/M) claims should be sheltered from the storm of denials versus those with a higher volume of claims for procedures.

Actions to take now

Practices should address implementation problems as quickly as possible to help mitigate negative impacts:

All in the family

Medicare fee-for-service Part B claims will be paid if a valid code in the proper family is provided. The first three characters, which refer to the general disease, must be correct, even if those that follow are not.

As an example, C81 is the family code for Hodgkin’s lymphoma, but it is not a valid code by itself. Valid codes for Hodgkin’s lymphoma include C81.00, C81.03, C81.10 or C81.90. Any one of them would be acceptable on a claim for Hodgkin’s lymphoma through Sept. 30, 2016. So, if the correct code is C81.03, but the code submitted is C81.00, the claim would be paid because it is a valid code in the correct family.

Note that coding specificity required by National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) continue to be required under ICD-10. Claims submitted must include the full number of characters required for a code, including the seventh character, if applicable.

Help is available

CMS has established an ombudsman’s office headed by William Rogers, M.D., in its ICD-10 Coordination Center in Baltimore. The ombudsman will triage issues and work with representatives in CMS’s regional offices to address physicians’ concerns. To submit issues to the ombudsman’s office, send an email to [email protected].

In addition, a complete list of the 2016 ICD-10-CM valid codes and code titles is posted on the CMS website at Codes are listed in tabular order as in the ICD-10-CM code book. – Irene E. Lombardo

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