Medicare Compliance & Reimbursement

Home care and hospice providers tell CMS they deserve more leniency.

In guidance posted last month, the Centers for Medicare & Medicaid Services (CMS) said that if physicians use the wrong ICD-10 code within the first year after Oct. 1, their claims will still be processed and paid, as long as they use an ICD-10 code from the correct code group.

But the grace period applies only to Part B physician services, according to the announcement. This means they are scheduled to get some leeway, while all other provider types are not.

According to one provider in the question-and-answer portion of the Aug. 12 CMS Open Door Forum for home care providers, however, if anything, home care and hospice providers should be more deserving of leniency because — unlike most physician practices — they do not routinely have certified coders on staff. Home health and durable medical equipment providers that rely on physician documentation to justify their claims will be left high and dry if the docs’ ICD-9-compliant documentation isn’t up to ICD-10 standards, added a DME provider in the Q&A.

These Providers Face Double Burden

Hospices will be especially burdened by ICD-10 with no grace period, since they also will be ramping up on new coding requirements as part of the 2016 final rule at the same time, a hospice provider noted in the forum.

CMS staff in charge of the matter were not in the forum. Whether CMS will extend the leniency granted to physicians to other types of providers is “an open question,” CMS’s Wil Gehne noted in the call.

Note: The CMS guidance is online at www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10-guidance.pdf.

CMS Weighs in on Coding for Claims Spanning Oct. 1

With the ICD-10 implementation deadline coming closer, it’s time to take a closer look at how you’ll submit claims during the transition.

The problem: Requests for Anticipated Payment (RAPs) for episodes that begin before Oct. 1 must contain ICD-9 codes, CMS reviews in MLN Matters article SE 1410. But claims with a “through” date of Oct. 1 or later must contain HIPPS codes based on ICD-10 codes.

The solution: CMS will “allow HHAs to use the payment group code derived from ICD-9-CM codes on claims which span 10/1, but require those claims to be submitted using ICD-10-CM codes,” CMS instructs. “This means that HHAs do not have to re-group the episode based on the ICD-10-CM codes.”

However, “this could result in some inconsistency between the HIPPS code and the ICD-10-CM codes on the claim,” CMS acknowledges. “CMS will alert medical reviewers at our MACs to ensure that the ICD-10-CM codes on these claims are not used in making determinations.” In other words, “the coding used to support the payment of the HIPPS code will be the ICD-9-CM codes that were used on the RAP and which are stored in the OASIS system,” CMS says.

See more details about claims spanning Oct. 1 in the article at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1410.pdf.