ICD-10 Post-Implementation Flexibilities Clarified
Below, you will find clarification regarding ICD-10 flexibilities for post-transition (as scheduled for October 1, 2015) from the Centers for Medicare and Medicaid Services (CMS.)nnCMS intended last week’s frequently asked questions (FAQs) on these flexibilities to provide clarification for healthcare organizations and providers. Apparently, two FAQs in particular did not do the trick and themselves required further clarification.nnThe first iteration of FAQs came in response to the July 6 joint announcement by the American Medical Association (AMA) and CMS that Medicare providers will not have claims rejected for 12 months after the ICD-10 compliance deadline “based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a code from the right family.”nnThe first clarification concerns what constitutes a valid ICD-10 code:n
All claims with dates of service of October 1, 2015 or later must be submitted with a valid ICD-10 code; ICD-9 codes will no longer be accepted for these dates of service. ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity. A three-character code is to be used only if it is not further subdivided. While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, if a valid ICD-10 code from the right family (see question 5) is submitted, Medicare will process and not audit valid ICD-10 codes unless such codes fall into the circumstances described in more detail in Questions 6 & 7.
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Many people use the terms “billable codes” and “valid codes” interchangeably. A complete list of the 2016 ICD-10-CM valid codes and code titles is posted on the CMS website, HERE. The codes are listed in tabular order (the order found in the ICD-10-CM code book). This list should assist providers who are unsure as to whether an additional 4th, 5th, 6th or 7th character is nnneeded. Using this free list of valid codes is straightforward. Providers can practice identifying and using valid codes as part of acknowledgement testing with Medicare, available through September 30, 2015. For more information about acknowledgement testing, contact your Medicare Administrative Contractor, and review the Medicare Learning Network articles on testing, such as SE1501.
nCMS has provided a few examples of invalid codes in the update.nnAnother clarification concerns what constitutes a family of codes:n
“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. Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters. 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.
nCMS has offered an additional example for Chrohn’s disease to help provides understand the concept.n
The full update is available here.
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This article originally posted on EHRIntelligence.com.
S05.51XA — Penetrating wound with foreign body of right eyeball, initial encounternW39.XXXA — Discharge of firework, initial encounternY92.833 — Campsite as the place of occurrence of the external causennIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2015 implementation date. Please don’t hesitate to 
Most reimbursement, one way or another, directly or indirectly is based on the RBRVS. The RBRVS updates and changes. It is doing so now quite rapidly! If you have not updated your billed charges in the last year or so, it is time to do so! Compare your billed charges to the current RBRVS and see if it is consistent. Be sure to adjust for site of service location! If your fees are wildly inconsistent or (OMG) below what you should be paid, it is time for an update!nnStay tuned for more Todd’s Tips!nn
About R. Todd Welter • MS, CPCnFounder and President of Welter Healthcare Partners
L55.0 —Sunburn of first degreenL55.1 —Sunburn of second degreenL55.2 — Sunburn of third degreenL55.9 — Sunburn, unspecifiednnIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2015 implementation date. Please don’t hesitate to 
Remember: fraud exists and it is amazingly/sadly common in healthcare. Tighten up your processes and procedures for paying bills, credit card usage and permissions. Differentiation of duties, cross checks and transparent reporting are great ways, all be it not ironclad ways, to stop or discourage fraud. It is ALWAYS the last person you would expect! “Why didn’t I see that” and “I was such a fool” seem to be the response after the F word shows up. Look for it, before it looks for you!nnStay tuned for more Todd’s Tips!nn
CMS announced earlier this month that it will provide greater flexibility during the transition to ICD-10 billing codes, easing physicians’ trepidation about the move by incorporating several changes that the AAFP urged the agency to adopt.nnWhen CMS introduced plans for ICD-10, family physicians raised concerns that moving to a new set of codes required additional time for staff training and the possibility of mistakes was too great to implement the codes so quickly. After all, the new system includes more than 68,000 codes — a far cry from the 13,000 ICD-9 uses. So primary care physicians and others sought an extension to prepare for the transition.nnCMS got that message loud and clear, and the agency has taken steps to ensure physicians don’t summarily fall victim to claims denials or audits for making innocent mistakes in coding.nn”The AAFP applauds CMS for taking actions to ease the transition to ICD-10,” said AAFP President Robert Wergin, M.D., of Milford, Neb., in a prepared statement. “Taken together, these provisions will enable family physicians to bill accurately, be paid appropriately and provide continued access to care for patients.”nnAlso during the grace period, Medicare claims will not be audited based on the specificity of the diagnosis codes used as long as they are from an appropriate family of codes.nnCMS is releasing additional guidance on flexibility in the auditing and quality reporting process as the medical community gains experience using the new set of codes.nn
In addition, physicians and allied health professionals who participate in CMS quality programs such as the Physician Quality Reporting System, the value-based payment modifier initiative and/or meaningful use of electronic health records will not be penalized during the 2015 reporting year for failure to select a specific code, as long as they have selected one from an appropriate family of codes. Moreover, practices will not be penalized if CMS encounters trouble in accurately calculating quality scores.nn”We have called for additional appeals and agency monitoring for reporting systems that determine appropriate payment for medical services based on quality measures and meaningful use of electronic health records,” Wergin said.nnPhysician practices can receive an upfront payment from Medicare administrative contractors as an option to protect against mistakes that could occur in coding.nn”The AAFP urged CMS to expand advance payment options for physicians, which will ensure that physician practices have an adequate revenue flow to maintain financial stability during the transition,” Wergin said.nnPhysicians should be aware that after Sept. 30, Medicare will no longer accept ICD-9 codes for service. Neither will it accept claims using both ICD-9 and ICD-10 codes.nnCMS will appoint an ombudsman in each regional office to handle ICD-10 questions, and the agency said it will announce ways to contact the ombudsmen as the October implementation date approaches.nnThe International Classification of Diseases, or ICD, was developed to standardize codes for medical conditions and procedures. The codes used in the United States have not been updated in more than 35 years and contain outdated terms.nn
ICD-10 was introduced with the intent of improving public health research and emergency response times by facilitating early detection of disease outbreaks and tracking adverse drug events. The new codes are also meant to support innovative payment models that improve overall quality of care.nThe grace period to adjust to the exclusive use of the ICD-10 codes is a welcome relief, and our academy deserves credit for representing our interests and concerns. I think that also goes for those of us who have had a hands-on course with the new codes, not because the use of these codes is in itself such a great challenge, but because the central problem is how to find the additional time needed to sort through 5 times as many codes. I think this is particularly so, when confirmation of a definitive diagnosis is pending further tests.nnNow, while we may be the last major country in the world to adopt usage of the ICD-10, I understand from speaking with primary care physicians in Canada, that they do not do the coding themselves because it decreases necessary time spent with the patient. So, all coding is deferred to trained support staff.nnAs practice demands on our time have already seriously decreased necessary visit time with our patients, I suggest that during the 12-month grace period, our academy develop and implement a plan together with CMS, to take this burden off of our shoulders and replace it with supportive training for competent coding by our office staff.nnThis