Home Health & Hospice Week

The Centers for Medicare & Medicaid Services has given suppliers advice that should get them past the front gate for newly reinstated diagnosis coding edits, but they question whether it will stand up to audit scrutiny in the long run.

On April 1, CMS reinstated the controversial edits that require durable medical equipment suppliers to use updated, fully specified diagnosis codes on their electronic claims even for capped rental patients who might have certificates of medical necessity that are up to three years old, CMS officials confirmed in an April 1 home health Open Door Forum attended by more than 230 people.

CMS tried to implement the edits Jan. 1 but had to quickly pull them back due to the maelstrom of confusion from suppliers who had never heard of the measure (see Eli's HCW, Vol. XII, No. 3, p. 20). Despite additional education from the DME regional carriers, industry representatives protest that suppliers still are woefully unprepared for the mandate and need more guidance from CMS on how to properly comply with it and secure payment.

Suppliers can't use outdated ICD-9 codes on their electronic claims any longer, but they don't always have to use the most specific version of a code either, reassured CMS officials in the forum. If suppliers can't solicit from the patient's physician a new, specific diagnosis code or description backing up the code, they can use the new, updated diagnosis code that represents the unspecified condition originally used on the CMN, they said.

Often, an obsolete unspecified three-digit ICD-9 code now has a new, valid four- or five-digit unspecified code, officials noted. Suppliers should feel safe in using that code to get their claims past the front-end edit that rejects any outdated diagnosis codes. ICD-9 codes are updated annually.

However, the CMS officials refused to write their guidance in stone. They insisted different departments within the agency must meet to discuss and agree on final solutions for the matter, even though the edits are already underway.

And suppliers, including a representative from Apria Healthcare Group Inc., protested that while these instructions will allow claims to clear the edits and enter the system, suppliers might be penalized down the road by post-payment audits that find the diagnosis codes on CMNs and claims don't match up and reject payment.

In the meantime, some suppliers are bypassing the edits by using paper claims, which aren't subject to the Health Insurance Portability and Accountability Act requirement for updated ICD-9 codes. But that avenue of escape may be short-lived.

A regulation is in the works to require electronic billing from all suppliers starting Oct. 16, a CMS source said. An exception is expected for companies with 10 or fewer employees.