ICD-10 Alert: FAQs and Guidance on Flexibility

On Monday July 27th, CMS issued Guidance on the recent CMS/AMA joint announcement regarding ICD-10 flexibilities. The Guidance comes in the form of a frequently asked questions (FAQs) document.

Below we’ve provided important information and highlights from the FAQs we think you’ll want to become familiar with as quickly as possible. Learn more at http://practicemax.com/

Key Highlights from the CMS ICD-10 Flexibility Guidance:

  • An ICD-10 Ombudsman will be in office by 10/1/15 to answer provider questions.
  • Do you realize that the recent CMS/AMA ICD-10 flexibilities and Guidance does NOT mean there will be another delay in the transition deadline?
  • Are you aware that if a claim is rejected, Medicare will provide detail whether it is due to:
    • An invalid code
    • Denied for lack of specificity for a National Coverage Determination (NCD) or Local Coverage Determination (LCD)
    • Other claim edit
  • The term “Family of Codes” is the same thing as the Three Character Category:
    • The codes included in each category are “clinically related”
    • The codes capture specific information about the nuances of the condition
    • Be sure to report a code and not a category number
  • The Guidance clarifies that there are still certain circumstances where a claim may be denied because:
    • The ICD-10 code is not consistent with applicable policies
    • The ICD-10 code is not valid (must contain the appropriate number of characters, up to 7)
  • The coding specificity necessary for NCDs and LCDs will not change with the recent CMS/AMA Guidance. Nor will the amount of specificity required for these policies change with ICD-10, with the exception of laterality.
  • It is mandatory for State Medicaid programs to process and pay claims with ICD-10 on or after the deadline (10/1/15) in a “timely manner”.
  • Note that the “flexibility” with regard to Medicare claims processing “does not apply to claims submitted for beneficiaries” with either primary or secondary Medicaid coverage.
  • Providers that don’t submit claims with valid and billable ICD-10 codes will not be provided Federal Matching Funds to offset the cost of denied claims.
  • Are you aware that this Guidance ONLY applies to Medicare?
    Neither Medicaid nor Commercial payors are mandated to grant flexibility in their claims adjudication for ICD-10.

At PracticeMax we understand the importance and significant efforts involved with transitioning your practice to ICD-10.

For more information about our ICD-10 tools and resources, or if you need help transitioning, please feel free to contact us.