Neurology & Pain Management Coding Alert

Heads up: LCDs could change what you submit.

Physician practices are barely beginning to adjust to ICD-10, but CMS has been busy sharing advice in response to provider queries. Read on for important information about the fee schedule, LCDs, and dual eligibility.

Follow Guidance for Part B Services

First things first: The official guidance only applies to Medicare fee-for-service claims from physician or other practitioner claims billed under the Medicare Fee-for-Service Part B physician fee schedule including only the technical component (TC).

This guidance does not apply to claims submitted for beneficiaries with primary or secondary Medicaid coverage. Federal matching funding will not be available for provider payments that are not processed through a compliant MMIS (Medicaid Management Information Systems) and supported by valid, billable ICD-10 codes.

"Because we must follow CMS guidelines for our billing, this helps us," says Elizabeth Earhart, CPC, a coder in Millersville, PA. "My office does not participate with Medicaid, so we don't have to worry about it. As long as we use the codes within our scope, we will be fine for this transition and reimbursement."

Why only Medicare: The reason CMS focused on Part B claims is because many physicians are in small practices that need additional flexibility to gain experience with the ICD-10 coding set. Claims billed under the Part B physician fee schedule are paid using CPT^® codes instead of ICD-10 codes. Other services, such as institutional services, are paid based on the ICD-10 codes.

Heed the disclaimer: The recent guidance does not mean that no claims will be denied if they are submitted with an ICD-10 code that is not at the maximum level of specificity. In certain circumstances, a claim may be denied because the ICD-10 code is not consistent with an applicable policy, such as Local Coverage Determinations (LCD) or National Coverage Determinations (NCD). This reflects the fact that current automated claims processing edits are not being modified as a result of the guidance.

Submitters will know whether the claim was rejected because it was not a valid code or because of a lack of specificity required for an LCD or NCD, or other claim edit. Submitters should follow existing procedures for correcting and resubmitting rejected claims and issues related to denied claims.

Established time limits to process claims: Section 1842(c)(2) of the Social Security Act requires Medicare contractors to make payment on not less than 95 percent of "clean claims" within 30 calendar days. If there are Medicare systems issues that interfere with claims processing, CMS and the MACs will disseminate information on how to access advance payments.

Pay Attention to Your LCDs

Although Medicare review contractors will not deny claims based solely on the specificity of an ICD-10 diagnosis for this first year (provided it's a valid code from the right code family), you still need to double check some other paperwork.

Case in point: The CMS guidance does not change the coding specificity required by the NCDs and LCDs. Coverage policies that currently require a specific diagnosis under ICD-9 will continue to require a specific diagnosis under ICD-10. It is important to note that these policies will require no greater specificity in ICD-10 than was required in ICD-9, with the exception of laterality. Remember to check the NCDs and LCDs at http://www.cms.gov/medicare-coverage-database/.

"The impact will be minimal as long as we follow our guidelines and adhere to the LCDs," Earhart says.

Scope of audits: The Medicare fee-for-service audit and quality program flexibilities only pertain to post payment reviews. ICD-10 codes with the correct level of specificity will still be required for prepayment reviews and prior authorization requests. Points related to this guideline include:

• Each commercial payer will have to determine whether it will offer similar audit flexibilities. As of now, this flexibility extends only to services covered by Medicare.
• Medicare Advantage risk adjustment payment and audit criteria remain unchanged.
• Coding guidelines Medicare Advantage plans are unchanged.
• The Medicare review contractors only review Medicare fee-for-service claims. This Guidance does not apply to the Medicare Advantage plans.
• The Medicare fee-for-service audit and quality program flexibilities have not been expanded to other claim types. They only apply to physicians and other practitioners who bill under the Medicare Fee-for-Service Part B physician fee schedule.
• Medicare's processes regarding what elements are crossed over to supplemental payers (including commercial payers and State Medicaid Agencies) will be unchanged as a result of the flexibilities.
• Medicare fee-for-service audit and quality program flexibilities will not affect the Medicare crossover claims and the crossover process.

Remember the Policy on Dual Eligible Beneficiary

State Medicaid programs are required to process submitted claims that include ICD-10 codes for services furnished on or after Oct. 1 in a timely manner. If the claims processing verifies that the individual is eligible, the claimed service is covered. Once all administrative requirements for a Medicaid claim have been met, payment may be made, taking into account the amount payable by Medicare. Consistent with these processes, Medicaid may deny claims based on system edits in an event when a diagnosis code is not valid.

ICD-10 ombudsman: The ICD-10 ombudsman is Dr. William Rogers. You can contact him if you have questions by emailing ICD10_Ombudman@cms.hhs.gov. He will listen to issues affecting suppliers and providers alike, and will evaluate any specific issues that arise during implementation. Moreover, CMS's ICD-10 Coordination Center will also be actively monitoring to quickly identify and initiate resolution of issues that may arise as a result of the big transition.

Final takeaway: In the words of Earhart, "Many of the payers are saying they will follow CMS in not denying for incorrect coding as long as the ICD-10 code is within the scope of practice." She adds further, "I hope they would send us corrections so we know what to expect and adjust to what should be coded."