Health Information Compliance Alert

If you haven’t converted to the 5010 platform, now is the time to do so, says CMS.

The Oct. 1, 2014 date for transitioning to ICD-10 is firm and it’s no use hoping for further delays. The Centers for Medicare & Medicaid Services (CMS) clarified in its April 18 webinar, “Begin Transitioning to ICD-10 in 2013,” that this date applies to everyone — Medicare, Medicare Advantage, and Medicaid.

CMS will be done with its computer system work so it can process ICD-10 codes by this October, giving the agency a full year of testing before you actually submit ICD-10 codes next year, said CMS’s Sarah Shirey-Losso during the call.

In addition, if CMS documents have created confusion for you about the ICD-10 implementation date, know that the agency is working on the problem. “Some of our articles and CRs refer to the prior ICD-10 implementation date of October 1st, 2013,” said Shirey-Losso. “Because a lot of our instructions were released prior to the official change in the date, we made a decision not to reissue each and every change request and memo and article already published, since the date change applied to all prior instructions. We also included a link to all previously issued MLN articles and change requests to the official notification of the change in the implementation date to October the 1st of 2014.”

And although CMS is working to convert national coverage decisions (NCDs) to feature ICD-10 codes instead of the current ICD-9 codes, the agency has found that not all NCDs are appropriate for translation, particularly those that are quite old and contain outdated procedures. “Like any good vintage, we have some that are drinkable and some that aren’t,” said CMS’s Janet Anderson Brock during the call. “If the NCD really dealt with non-coverage of an item or service, and that non-coverage employed edits in our shared systems space on a HCPCS code rather than a diagnosis code, there was really no point in putting it through a translation process, and therefore we put that to the side,” she said.

Therefore, out of 330 NCDs in existence, CMS has translated about 90 into ICD-10 codes, Brock said. When the agency releases the new policies, you’ll be able to see the historical ICD-9 codes as well as the applicable ICD-10 codes for each particular procedure. “So you get sort of two bangs for the buck,” Brock noted. “When we put out new policy we try to tell you what you’re getting now and what’s coming.”

For example: CMS recently revised Transmittal 2421 which covers payment regulations for intensive behavioral therapy for obesity (G0447), indicating it will pay for the service under ICD-10 when linked to ICD-10 codes Z68.30-Z68.45, which refer to the patient’s BMI. You can read the complete policy at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2012-Transmittals-Items/CMS1256805.html.

Unfortunately, however, the new NCDs won’t solve all of your conversion problems. “Only really 15 to 20 percent of Medicare coverage is actually spelled out in a National Coverage Determination,” Brock said during the call. “The vast majority of items and services covered under Medicare are actually covered through LCDs or covered on a case-by-case basis.” For those, she advises going back to CMS’s “GEMs,” which show the ICD-10 code options available to you.

Start Internal Testing ASAP

If your practice is currently wondering whether you should be taking any steps to transition to ICD-10 right now, CMS’s Denesecia Green has the answer. “We’re asking everyone from now through the end of the year to start your internal testing,” she advised.

You cannot, however, submit your claims to CMS for testing, because the agency is not prepared to handle that. If you want to test a claim using ICD-10 codes with your MAC, contact the MAC for guidelines on how to do so, said CMS’s Stewart Streimer during the call. “Other than that, there will not be end-to-end testing. CMS has already got a vigorous testing plan in place to test our ability to handle a properly filled out claim from the front end to the back end. But we will not be testing claims from providers.”

Clearinghouses Can’t Fix All 4010 Problems

You should be working with your business partners to ensure that they will be prepared for ICD-10 come Oct. 1, 2014, and if you haven’t converted to the 5010 platform, now is the time to do that, because you cannot process ICD-10 claims under 4010, Green said.

Avoid this loophole: If you don’t yet use 5010 but you count on your clearinghouse to convert all of your claims from 4010 to 5010, that won’t solve the problem you’ll face in 2014. “Clearinghouses will not be able to take your 4010 claim and translate that and add in the ICD-10 code for you,” Green advised.

And if CMS’s frequent references to “Medicaid” and “Medicare Fee-for-Service” have you believing that Medicare Advantage is immune to the ICD-10 transition, think again. “This compliance date applies to everyone,” Green said. “So everyone — Medicare, Medicare Advantage, Medicaid — all industry will have to transition from ICD-9 to ICD-10.”

However, worker’s compensation insurers will not be required to implement ICD-10, Green said. Although some worker’s comp payers will transition to ICD-10, others may not, so you’ll unfortunately have to contact your state worker’s compensation insurer for details on how they’d like you to bill effective Oct. 1, 2014.

Keep in mind that since CMS will not be updating ICD-9 going forward, worker’s compensation insurers that steadfastly refuse to adopt ICD-10 will eventually come up short on available codes as new diagnoses are introduced or revised and ICD-9 does not update, said CMS’s Pat Brooks during the call. “So I don’t know how long worker’s comp or auto insurers could viably keep mandating ICD-9-CM, since we will not maintain ICD-9-CM any further.”