Urology Coding Alert

Question: I heard that CMS issued a statement saying we’ll have a one-year reprieve on ICD-10. My colleagues have said that means we don’t have to learn ICD-10 for this fall anymore but I disagree. Can you give us the details on the CMS’s recent announcement?  

Colorado Subscriber

Answer: CMS has stated that if you can at least list an ICD-10 code from the right “family,” your Medicare administrative contractor (MAC) will pay your claims for the first calendar year following the Oct. 1, 2015 implementation date even if the code you report is an unspecified or incorrect diagnostic code but is within the correct family of codes.

The AMA (which wanted to delay ICD-10 implementation) and CMS (which insisted that the show must go on) recently announced that they’ve forged a partnership to help practices during the final three months before ICD-10 implementation in response to urging from the provider community. As a result, the two groups released guidance that included four points to ease your code-set transition.

Compromise 1: Incorrect ICD-10 codes won’t automatically trigger denials. If you use the wrong ICD-10 code within the first year after October 1, your MAC will still process and pay your claim will, as long as you use an ICD-10 code from the correct code category, CMS says.

Keep in mind, however, that this doesn’t let you off the hook completely — you still have to use a valid ICD-10 code on your claim and it has to be from the correct code family. In addition, your claim could still be denied for other reasons besides the ICD-10 code’s specificity.

Compromise 2: If you use the wrong ICD-10 code for quality reporting, you won’t face penalties. Whether you’re reporting for PQRS, value-based modifiers (VBM), or meaningful use (MU), no penalties will apply as long as you use an ICD-10 code from the right code family.

Compromise 3: You could be entitled to an advance payment if your MAC faces “administrative problems.” If your MAC experiences a system malfunction or has trouble implementing ICD-10, you might be able to collect a conditional partial payment until the issues are resolved.

The advance payments — which require repayment — do not apply if the physician is unable to submit a valid claim for services rendered, CMS clarifies. However, if a Medicare systems issue interferes with claims processing, CMS and the MACs will post information on how you can request an advance payment.

Compromise 4: You’ll have access to an ombudsman and a communications center to answer your questions. CMS is anticipating issues and questions during the ICD-10 transition, and is therefore creating a “communication and collaboration center” as well as appointing an ICD-10 ombudsman to resolve issues and address concerns. “As we get closer to the Oct. 1, 2015 compliance date, CMS will issue guidance about how to submit issues to the Ombudsman,” CMS said in the guidance.

Resource: To read the CMS/AMA guidance, visit www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10-guidance.pdf.