Outpatient Facility Coding Alert

Ensure the code belongs to the right family and avoid denials.

If ICD-10 implementation still has you stressed, remember that CMS has built in some grace periods to ease the transition. Here’s the latest news you need to know.

Although your goal should always be to aim for the correct level of specificity, during this first year of implementation Medicare review contractors will not deny physician or practitioner claims billed under the Part B physician fee schedule, as long as the claim has a valid code from the right diagnosis family. However, the review is made through either automated medical review or complex medical record review to look into the specificity and granularities of the ICD-10 diagnosis code.

“Furthermore, an EP (eligible provider) will not be subjected to a penalty if CMS experiences difficulty calculating the quality scores for PQRS, VBM, or MU due to the transition to ICD-10 codes,” CMS information states.

“If Medicare contractors are unable to process claims as a result of problems with ICD-10, CMS will authorize advance payments to physicians,” a message from AMA president Steven Stack, MD, noted in a viewpoint piece on the group’s website (http://www.ama-assn.org/ama/ama-wire/post/cms-icd-10-transition-less-disruptive-physicians).

Pay heed to 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 (LCDs) or National Coverage Determinations (NCDs). This reflects the fact that current automated claims processing edits are not being modified as a result of the guidance.

Get to know reasons for claim rejection: Submitters will get to know whether the claim was rejected because it was not a valid code or because of a lack of specificity required for a National Coverage Determination (NCD), Local Coverage Determination (LCD), 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% 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.

Helpline: To help and triage the physicians and the coders’ issues relating conversion, the CMS has created a Communication Center.

The ICD-10 Ombudsman, Dr. William Rogers, serves as a one-stop shop for provider questions and concerns about ICD-10 and is an internal advocate for providers on ICD-10-related matters. You can contact him for your doubts and questions by emailing ICD10_Ombudsman@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. It will identify and assign issues for resolution, and coordinate with the external community about the ICD-10 implementation. This Center is responsible for coordinating post-implementation operations with a focus on delivering a high-quality experience for internal and external stakeholders.

The Coordination Center is open Monday-Friday from 8 am to 6:30 p.m. Eastern time.

Final takeaway: In the words of Elizabeth Earhart, CPC, a coder in Millersville, PA, “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.”

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