Medicare Compliance & Reimbursement

One-year grace period is good, but two years would be better, some say.

Errors in your diagnosis coding could throw your billing completely out of whack — and the Oct. 1 implementation of ICD-10 practically guarantees at least some coding mistakes by all providers. But the good news is Part B providers won’t suffer claim denials for ICD-10 blunders, as long as you’ve come close enough to the right code.

On July 6, the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) announced four provisions that aim to ease healthcare providers’ burdens and provide more flexibility in claims payment and quality reporting during the ICD-10 transition.

These provisions appear to apply to only Part B (physician) providers, however. That means Part A (skilled nursing facility, inpatient hospital, home health, hospice) providers may still face potential reimbursement issues.

How a Petition Might’ve Been the Last Straw

Since earlier this year, the AMA and 100 other physician groups have lobbied to CMS regarding their concerns about the ICD-10 transition. Electronic health record (EHR) software provider Practice Suite also submitted a petition, signed by hundreds of supporters, to President Barack Obama on June 8 asking for the following concessions:

• For 12 months following Oct. 1, 2015, no payers can deny physician claims based solely on ICD-10 diagnosis coding errors. Payers should report any ICD-10 errors and send them with reimbursements and requests for corrected claim information.

• All payers should forgive innocent erroneous ICD-10 coding and claim errors, and CMS should not allow payer audits on these claims.

• Payers’ inability to process ICD-10 claims should not be a basis to withhold or delay claim payments. If necessary, payers should make advance payments.

• For 12 months following Oct. 1, 2015, CMS should bar payers from enforcing the additional clinical documentation required under ICD-10.

Petitioners achieved nearly all requested concessions. Here are the recent provisions to soften providers’ transition to ICD-10:

1. You’re Saved from Certain Claims Denials

For the first year ICD-10 is in place (Oct. 1, 2015 through Oct. 1, 2016), CMS will neither deny nor audit Medicare Part B claims based solely on the specificity of your diagnosis codes, as long as they’re from the correct family of ICD-10 codes, according to the AMA. Essentially, this means that you won’t see Medicare payment denials for these errors while you’re becoming accustomed to coding under ICD-10.

“This transition period will give physicians and their practice teams time to get up to speed on the more complicated code set,” AMA president Steven Stack, MD said in a July 6 statement. CMS has instructed both Medicare Administrative Contractors (MACs) and Recovery Audit Contractors (RACs) to follow this policy.

“A giant burden was slightly eased for physicians with news of an ICD-10 transition grace period,” says Texas Medical Association president Tom Garcia, MD. “Having a year to convert our medical practices — and the entire American healthcare infrastructure — to this gargantuan new coding system without as many penalties for errors will allow us to spend more time practicing medicine and focusing on patients.”

2. Don’t Worry About These Quality-Reporting Penalties

Also, Part B providers won’t suffer quality-reporting penalties during the first year of ICD-10 implementation if they use the wrong ICD-10 code but instead a code from the correct ICD-10 code family, the AMA explained. This includes penalties for the Physician Quality Reporting System (PQRS), the value-based payment modifier, and meaningful use.

3. Get Advance Payments When This Happens

You’ll receive advance payments for eligible claims if Medicare contractors are unable to process them due to problems with ICD-10, the AMA said. This means no payment disruptions during the ICD-10 transition period. Also, if CMS has problems calculating your quality scores for the value-based payment modifier, PQRS or meaningful use, CMS won’t apply any penalties.

4. Take Advantage of Help with Transition Problems

Finally, CMS will establish a communication center to monitor ICD-10 issues and resolve them quickly, as well as implement an “ICD-10 ombudsman” to triage physician issues, according to the AMA. CMS has also recently released a plethora of educational materials aimed to help healthcare providers and other stakeholders to successfully make the ICD-10 transition (see “Beef Up Your ICD-10 Coding Knowledge with These New Resources” on page 123).

Healthcare Big Shots Call for 2 Years, Not Just 1

Not enough? Garcia is concerned that one year won’t be long enough for all healthcare providers to overhaul their coding practices. “I’m worried that the software vendors, government, and other links in this complex chain won’t be ready,” he laments. “If so, physicians will suffer burdensome bureaucratic and financial consequences, and their patients will suffer delays in care.”

Garcia hopes that CMS will extend the one-year penalty-free and audit-free grace period if providers need more time. “One year is a good start,” but two years of transition time “would have resulted in a much less disastrous transition to this overwhelmingly complicated new coding system,” he says.

Along with Texas, the California Medical Association and other large state medical associations in New York and Florida have also urged CMS and Congress to support a two-year grace period instead of just one year.

Other physician groups are also calling for further concessions. The American Academy of Family Physicians (AAFP), for example, is asking for additional appeals and agency monitoring for reporting systems that affect payment based on quality measures and meaningful use of EHRs.

“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,” said AAFP president Robert Wergin, MD in a July 7 statement.