Home Health & Hospice Week

Centers for Medicare & Medicaid Services representatives shed light on this and several other coding issues during the agency's May 18 "ICD-10 National Provider Teleconference." Here are five FAQs that are most relevant to your home care organization.

Question 1: How will CMS handle claims that span from before Oct. 1, 2013 through dates after Oct. 1, 2013? Should the provider use ICD-9 or ICD-10 codes for these claims?

Answer: CMS is mulling how to handle this situation, but hasn't yet arrived at a firm decision. "We are getting very close to finalizing our decision for all claim types, including professional claims, supplier claims, and the various types of institutional claims," said CMS's Sarah Shirey-Losso during the call. "Some claims will continue to use the discharge date, some will use the 'from' date, and some may be required to be split," she said.

CMS is currently working on a final decision, which the agency will issue in a "Change Request" document this summer.

If, however, you submit a claim for a single date of service, you'll submit ICD-9 codes for dates of service through Sept. 30, 2013, and ICD-10 codes for dates of service Oct. 1, 2013 and thereafter. For instance: If you send in a claim on Oct. 15, 2013, but the date of service is Sept. 1, 2013, you'll still use ICD-9 codes.

Question 2: Will Medicaid require ICD-10 codes as well?

Answer: You can rest assured that Medicaid insurers will be transitioning to ICD-10 as of the Oct. 1, 2013 date, said CMS's Denise Buenning during the call. CMS is working with Medicaid administrators to ensure that they are compliant by the implementation date, she noted.

Question 3: What are the penalties for providers that are covered under HIPAAwho choose not to use ICD-10 codes as of Oct. 1, 2013?

Answer: Your claims will be denied -- and you technically could face fines since use of the ICD-10 codes falls under the HIPAA transaction code set regulations, CMS reps noted. "From a practical standpoint, as of service dates of Oct. 1, 2013, if you don't use ICD-10 codes, most likely your claims will be returned and [you] will be asked to transition to ICD-10," Buenning said.

"The penalties are the same penalties that any HIPAA entity would be subject to," Buenning noted. "I think most of you are familiar with the ongoing HIPAA transaction code set penalty that calls for a maximum of $25,000 per covered entity per year, but the HITECH legislation of last year actually upped those transaction and code set penalties, and they can be as much as $1.5 million per entity per year. So obviously it behooves everybody -- Medicare and Medicaid inclusive -- to make sure we are compliant with these ICD-10 codes by the Oct. 1, 2013 date," she added.

Question 4: Medicare local coverage decisions (LCDs) currently list ICD-9 codes for coverage. Will contractors issue updated LCDs to the public prior to the Oct. 1, 2013 implementation date that show the ICD-10 codes?

Answer: The answer to that isn't yet crystal clear. "The LCDs will be translated because they will need to be translated," said CMS's Lisa Eggleston during the call. But "as it relates to having them available to the public prior to the implementation date, that I'm not sure of, because we are working fast and furious on all of our ICD-10 implementation efforts."

Question 5: When will CMS finalize the ICD-10 code set?

Answer: As of this October, you'll see an ICD-10 code set that's pretty close to how the final will look. "The final version will be the one that will be implemented in FY 2014 [issued on Oct. 1, 2013]," said CMS's Pat Brooks. "So what we're doing each year we update it, we're telling you the current version we're working from. We will have the last major update in FY 2012 [which will be implemented Oct. 1, 2011], but we're warning you that we could add some more codes because of new technology and new procedures, but each year has a version and that's the official version for the current year" (see related news item, p. 167).