CMS announces it won't deny claims for first year after ICD-10 implementation

CMS announces it won’t deny claims for first year of ICD-10 transition

As the ICD-10 implementation date draws nearer with no signs of another delay, physicians are starting to take preparations seriously. Many who have put off training their staff and upgrading their electronic health record systems have recently begun these important tasks to prevent setbacks once Oct. 1 comes and goes.

CMS releases new ICD-10 guidance 
Many health professionals are fearful that the major transition will leave them struggling to keep up with the evolving health care industry. A lot of providers are also concerned that their claims will be denied as a result of even minor ICD-10 errors as they file claims for the first time in October. To help ease any anxiety physicians are feeling, the Centers for Medicare and Medicaid Services has provided a new guide for health professionals as they take on the new codes.

The guidance features a clause that states Medicare will not deny any claims due to minor ICD-10 mistakes for the first year after the implementation date. Minor errors include mistakes with specificity of the new diagnosis codes – as long as the codes come from the correct group, the CMS will not deny claims. However, physicians will have to be familiar with the detailed codes by the time October 2016 rolls around or the CMS will start to deny their claims, which could cause serious setbacks for practices.

"While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician or practitioner used a valid code from the right family," stated the CMS officials in the guidance. "However, a valid ICD-10 code will be required on all claims starting on October 1, 2015."

Collaboration and communication platforms on the horizon
The CMS is prioritizing the identification of common ICD-10 implementation problems through enhanced communication platforms. The ICD-10 Ombudsman will help the agency not only pinpoint, but understand the root of even the most minor issues experienced by providers during the transition. There will soon be further information provided regarding how providers can reach out to Ombudsman with feedback. This will help the CMS develop strategies to solve these issues and prevent them in the future. 

Incorrect specificity of the ICD-10 codes is expected to be one of the most prevalent issues during the transition process. This is why physicians will not have to undergo source verification and auditing as long as the codes used come from the correct family of codes, according to the new guidance. 

"When the Part B Medicare Contractors are unable to process claims within established time limits because of administrative problems, such as contractor system malfunction or implementation problems, an advance payment may be available," explained the CMS in its guidance. The CMS described advanced payments as conditional partial payments that require repayment and can be issued once the conditions described in CMS regulations 42 CFR Section 421.214 are met. 

While this news is sure to serve as a source of relief for many of the physicians across the industry, it is still essential for providers to properly prepare for the new codes and remember that valid ICD-10 codes are still required for billing after the implementation date. Providers should make plans to enhance communication with their EHR vendors and payers and train their staff in order to properly gear up for a smooth transition to the ICD-10 coding set.