ED Coding and Reimbursement Alert

Good news:  CMS will be flexible on absolute accuracy in your code assignments.

If your ED practice is still hoping for last minute reprieve from transitioning to ICD-10 on Oct. 1, you can let go of that dream; but you can be thankful for a stress-relieving compromise, courtesy of the AMA and CMS. 

Read on for specifics on how the AMA’s agreement with CMS allows for flexibility in the claims auditing and quality reporting process.

Set in stone: CMS has been clear that the Medicare claims processing systems will not have the capability to accept ICD-9 codes or be able to accept claims for both ICD-9 and ICD-10 codes for dates of services after Sept. 30, 2015.

Silver lining: Although a valid ICD-10 code will be required on any Medicare claims for service beginning Oct. 1, 2015, Medicare contractors will not deny Part B claims through either automated medical review or complex medical review audits based solely on the specificity of the ICD-10; however, the provider must use an ICD-10 code from the correct code family.

“The agency is trying to help practices be ready by providing easy to use tools, and appointing a new ICD-10 Ombudsman to help solve problems with the transition,” says Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth a national ED coding and billing company.

Find Out What “Family of Codes” Means

The term “family of codes” equates to 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 S52 (Fracture of forearm) contains a number of specific codes that capture information on the type of fracture as well as information on the specific location of the injury. Examples include: S52.0 (Fracture or upper end of the ulna), which has four characters; S52.01 (Torus fracture of upper end of the ulna), which has five characters; and S52.012 (Torus fracture of upper end of the left ulna), which has six characters.

You must report a valid full code and not simply a category number. In many instances, the code will require more than three characters in order to be valid. This is a significant concession from CMS for the first year of implementation and allows some additional time to perfect your diagnosis code selection under ICD-10, Granovsky explains.

Look for a Quality Reporting Reprieve, Too

As long as you use a code from the correct family of ICD-10 codes, you’re okay as far as penalties go.

Medicare clinical data review contractors will not subject providers to the PQRS, Value Based Modifier (VBM) or Meaningful Use (MU) penalty during primary source verification or auditing related to the additional specificity of the ICD-10 diagnosis code for quality reporting completed for program year 2015. In addition, an eligible professional 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 eligible professional submitted the requisite number/type of measures and appropriate domains on the specified number/percentage of patients, and the eligible professional’s only errors are related to the specificity of the ICD-10 diagnosis code; however, the physician or eligible professional must still report a valid code from the correct ICD-10 code family, Granovsky explains.

But take note:  The audit and quality program flexibilities only pertain to post-payment reviews. ICD-10 codes with the correct level of specificity will be required for prepayment reviews and prior authorization requests, warns Granovsky.

Check Local Coverage Decisions For Required Code Specificity

The recent guidance allowing leeway of the ICD-10 code selection does not override the coding specificity required by CMS national or local coverage decisions. Any coverage policies that currently required a specific diagnosis under ICD-9 will continue to require a specific diagnosis under ICD-10. CMS points out that these policies will require no greater specificity in ICD-10 than was required in ICD-9, with the exception of laterality, which does not exist in ICD-9. LCDs and NCDs that contain mention of right side, left side, or bilateral ICD-10 codes do not allow for unspecified choices. You can find your relevant CMS NCDs and LCDs at http://www.cms.gov/medicare-coverage-database/.

Translation: If your claim is rejected, you will know that it was rejected because it was not a valid code rather than a denial for lack of specificity required for a NCD or LCD or other claim edit. Be sure to follow existing procedures for correcting and resubmitting rejected claims and issues related to denied claims, says Granovsky.

Advanced Payments May be Available If Contractors Experience Major Problems

When the Part B Medicare contractors are unable to process claims within established time limits because of administrative problems, such as contractor system malfunction or implementation problems, you may be able to get an advance payment. 

An advance payment is a conditional partial payment, which requires repayment, and may be issued when the conditions described in CMS regulations at 42 CFR Section 421.214 are met.

To apply for an advance payment, the Medicare physician needs to submit the request to their appropriate Medicare Administrative Contractor (MAC). Should there be Medicare systems issues that interfere with claims processing, CMS and the MACs will post information on how to access advance payments. CMS does not have the authority to make advance payments in the case where a physician is unable to submit a valid claim for services rendered.

CMS also detailed its operating plans for the ICD-10 implementation. Upcoming milestones include:

• Setting up an ICD-10 communications and coordination center, learning from best practices of other large technology implementations that will be in place to identify and resolve issues arising from the ICD-10 transition.

• Offering ongoing Medicare acknowledgement testing for providers through September 30th.

• Providing additional in-person training through the “Road to 10” for small physician practices.

What About Medicaid Claims?

The official CMS guidance only applies to Medicare fee-for-service claims from physicians or other practitioner claims billed under Part B physician fee schedule. This guidance does not apply to claims submitted for beneficiaries with Medicaid coverage, either primary or secondary as for dual eligible patients, says Granovsky.

State Medicaid programs are required to process submitted claims that include ICD-10 codes for services furnished on or after October 1 in a timely manner. Claims processing verifies that the individual is eligible, the claimed service is covered, and that all administrative requirements for a Medicaid claim have been met. If these tests are met, payment can be made, taking into account the amount paid or payable by Medicare.

Consistent with those processes, Medicaid can deny claims based on system edits that indicate that a diagnosis code is not valid, adds Granovsky.

Don’t Expect Commercial Payers to Follow Medicare 

Will your health plan follow CMS’s lead on minimizing financial penalties as health care providers learn the new code set? The official guidance only applies to Medicare fee-for-service claims from physician or other practitioner claims billed under the Medicare Fee-for-Service Part B physician fee schedule. Each commercial payer will have to determine whether it will offer similar audit flexibilities.

However commercially operated Medicare Advantage plans should follow CMS polices on ICD-10 coding.

Most major payers have not yet officially announced intentions to follow Medicare’s lead on accepting a valid diagnosis from the correct code family even if it is not the most granular code available.

Best practice: You should check with each payer in your mix to verify their position, but your best bet is to be ready to code to the most accurate level ICD-10 allows in order to avoid any delay in commercial payments, says Granovsky.