More Q&As Regarding ICD-10 Guidance and Flexibilities

On July 6, 2015, the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) released a joint statement about their efforts to help the provider community get ready for ICD-10. This statement included guidance from CMS that allows for flexibility in the claims auditing and quality reporting processes.

In response to questions from the health care community, CMS has released “Clarifying Questions and Answers Related to the July 6, 2015 CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities,” which provides answers to the most commonly asked questions.

Q: When will the ICD-10 Ombudsman be in place?

A: The Ombudsman will be in place by Oct. 1, 2015.

Q: Does the guidance mean there is a delay in ICD-10 implementation?

A: No. Medicare claims with a date of service on or after Oct. 1, 2015, will be rejected if they do not contain a valid ICD-10 code. The Medicare claims processing systems do not have the capability to accept ICD-9 codes for dates of service after Sept. 30, 2015, or accept claims that contain both ICD-9 and ICD-10 codes for any dates of service. Submitters should follow existing procedures for correcting and resubmitting rejected claims.

Q: What is a valid ICD-10 code?

A: ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity. A three-character code is to be used only if it is not further subdivided. To be valid, a code must be coded to the full number of characters required for that code, including the 7th character, if applicable. A complete list of the 2016 ICD-10-CM valid codes and code titles is posted on the CMS website.

Q: What should I do if my claim is rejected? Will I know whether it was rejected because it is not a valid code versus denied due to a lack of specificity required for a NCD or LCD or other claim edit?

A: Yes. Submitters will know if a claim was rejected because it was not a valid code versus a denial for lack of specificity required for a NCD or LCD or other claim edit. Submitters should follow existing procedures for correcting and resubmitting rejected claims and issues related to denied claims.

Q: What is meant by a family of codes?

A: “Family of codes” is the same as the ICD-10 three-character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. One must report a valid code and not a category number. In many instances, the code will require more than 3 characters to be valid.

Q: Does the recent guidance mean no claims will be denied if they are submitted with an ICD-10 code that is not at the maximum level of specificity?

A: 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 or National Coverage Determinations. (See Question 7 for details). This reflects that current automated claims processing edits are not being modified as a result of the guidance. In addition, the ICD-10 code on a claim must be a valid ICD-10 code. If the submitted code is not recognized as a valid code, the claim will be rejected. The physician can resubmit the claims with a valid code.

Q: National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) often indicate specific diagnosis codes are required. Does the recent guidance mean the published NCDs and LCDs will be changed to include families of codes rather than specific codes?

A: No. 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/practitioner used a valid code from the right family of codes. The Medicare review contractors include the Medicare Administrative Contractors, the Recovery Auditors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor. The recent 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 these policies will require no greater specificity in ICD-10 than was required in ICD-9, with the exception of laterality, which does not exist in ICD-9. LCDs and NCDs that contain ICD-10 codes for right side, left side, or bilateral do not allow for unspecified side. The NCDs and LCDs are publicly available and can be found here.

Q: Are technical component only and global claims included in this same CMS/AMA guidance because they are paid under the Part B physician fee schedule?

A: Yes, all services paid under the Medicare Fee-for-Service Part B physician fee schedule are covered by the guidance.

Q: Do the ICD-10 audit and quality program flexibilities extend to Medicare fee-for-service prior authorization requests?

A: No, the audit and quality program flexibilities only pertain to post payment reviews. ICD-10 codes with the correct level of specificity will be required for prepayment reviews and prior authorization requests.

Q: If a Medicare paid claim is crossed over to Medicaid for a dual-eligible beneficiary, is Medicaid required to pay the claim?

A: 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. Claims processing verifies that the individual is eligible, the claimed service is covered, and that all administrative requirements for a Medicaid claim have been met. If these tests are met, payment can be made, taking into account the amount paid or payable by Medicare. Consistent with those processes, Medicaid can deny claims based on system edits that indicate that a diagnosis code is not valid.

Q: Does this added ICD-10 flexibility regarding audits only apply to Medicare?

A: 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. This guidance does not apply to claims submitted for beneficiaries with Medicaid coverage, either primary or secondary.

Q: Will CMS permit state Medicaid agencies to issue interim payments to providers unable to submit a claim using valid, billable ICD-10 codes?

A: Federal matching funding will not be available for provider payments that are not processed through a compliant MMIS and supported by valid, billable ICD-10 codes.

Q: Will the commercial payers observe the one-year period of claims payment review leniency for ICD-10 codes that are from the appropriate family of codes?

A: 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. Each commercial payer will have to determine whether it will offer similar audit flexibilities.

Physicians Not Ready for ICD-10, New Survey Says

Nearly 25 percent of physicians’ offices will not be ready when ICD-10 is implemented Oct. 1, and another 25 percent are unsure of their state of readiness, according to a new survey by the Workgroup for Electronic Data Interchange (WEDI), the nation’s leading nonprofit authority on the use of health information technology.

Alabama Medicaid to Honor Physician ICD-10 ‘Grace Period’ for Coding Errors

In response to a request from the Medical Association, Alabama Medicaid will not penalize physicians for coding errors under ICD-10 as long as a valid ICD-10 code from the correct “family of codes” is used. This follows a similar policy by CMS for Medicare Part B claims announced in early July.

“The inclusion of a transition or ‘grace period’ is significant as we believe that Alabama physicians and medical practices are not yet fully prepared for the switch from ICD-9 to ICD-10,” Association President Dr. Buddy Smith wrote in his letter to all health plans and insurers in Alabama requesting they follow the CMS guidelines for a coding error grace period. “While the Medical Association has been an outspoken opponent of ICD-10 and remains so, the inclusion of a grace period makes this federal mandate less problematic for medicine.”

In summary, while Alabama Medicaid will implement ICD-10 on Oct. 1, the Agency will allow a grace period during which physicians will not be penalized for ICD-10 coding errors as long as the ICD-10 code used is in the same “family of codes.”

A “family of codes” is the same as the ICD-10 three-character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. However, the code may require more than three characters to be valid.

To date only Medicare Part B, Blue Cross and Blue Shield of Alabama and Alabama Medicaid have granted a “grace period.”

Alabama Medicaid has more information about ICD-10 implementation and readiness details here. Even more information about ICD-10 readiness can be found in our ICD-10 Physician Resource Center.

Last Minute ICD-10 Items

Despite our best efforts, ICD-10 will be implemented Oct. 1, 2015.

No more delays. It’s going to happen next Thursday, Oct. 1, ready or not. Here comes ICD-10. While the Medical Association has been and remains an opponent of the forced switch to ICD-10, we fought it and in 2014 got a one-year delay. We continued fighting the mandated ICD-10 changeover in 2015, but when it became evident it would be implemented we worked diligently to soften the landing as much as possible.

In short summary, regarding ICD-10, the Association:

• Worked with the Alabama Congressional Delegation and chiefly Rep. Gary Palmer (R-AL 6) on his legislation to delay implementation even though the powerful forces of the tech, software and data processing industry overpowered us;
• Provided testimony to Congressional committees about the real world effects on medical practices through our late anti-ICD-10 champion Dr. Jeff Terry of Mobile, where Dr. Terry was often the lone voice opposing the mandated switch;
• Successfully ushered a joint resolution through the Alabama Legislature asking Congress for delay of or funding for medical practices in order to implement ICD-10;
• Worked with the media to raise awareness of the public to the unnecessary switch from ICD-9 to ICD-10 at this time;
• Successfully petitioned several health insurance entities including Medicare Part B, Alabama Medicaid, Blue Cross Blue Shield of Alabama and VIVA HEALTH to provide some form of grace period for ICD-10 physician coding errors; and,
• Provided CME opportunities on ICD-10 to help medical practices prepare for the transition.

Additionally, the Medical Association has compiled significant amounts of useful information on the ICD-10 transition. For more information about ICD-10 preparedness, check out the ICD-10 Physician Resources in the NewsCenter.

Problems with ICD-10 Implementation? Check Out These Tips…

Ready or not, tomorrow is the day. While the Medical Association has been and remains an opponent of the forced switch to ICD-10, we fought it and in 2014 got a one-year delay. We continued fighting the mandated changeover in 2015, but when it became evident it would be implemented, we worked diligently to soften the landing as much as possible.

Dr. Buddy Smith on ICD-10: “This should be a wake-up call … to be an advocate”

Medical Association President Buddy Smith, M.D., has had it with government mandates in medicine, likening ICD-10 to the proverbial “straw that broke the camel’s back.”

“It has gotten to the point of absurdity. We need more of the ‘practice’ of medicine and less of the ‘process’ of delivering medical care. We are forced to jump through hoops checking boxes that don’t do the first thing to improve patient care,” Dr. Smith said.

In his opinion, forced adoption of ICD-10 tops the list of practice aggravations and only adds to the frustrations an already overburdened physician workforce is having with their chosen profession.

Seeing the negative effect it would have on its members, over the past few years the Association worked with Congressman Gary Palmer (R-AL06) and the Alabama Delegation on legislation putting off ICD-10 adoption. The Association also worked with state media to raise awareness of the problems with ICD-10 and even the Legislature, ushering through a bipartisan resolution by Alabama’s two physician-Senators Tim Melson and Larry Stutts this spring urging Congress to either delay ICD-10 or find a way to offset the cost to medical practices. In the end, however, medicine was unfortunately unsuccessful, and the full effects will not be known for some time.

“We gave it our best, but with hospitals, insurance companies and the entire health care data and technology industry on the other side, the voices of physicians – like my dear friend the late Dr. Jeff Terry – were drowned out,” Dr. Smith said.

A silver lining, Dr. Smith says, was the Medical Association’s success in petitioning Blue Cross Blue Shield of Alabama and VIVA HEALTH along with Alabama Medicaid to implement “grace periods” for physician coding errors made under ICD-10 as is being allowed under Medicare Part B. Few other states have any commercial payors implementing any type of “grace period.”

“Most of our colleagues in other states will have zero leeway if they miscode for anyone other than a Medicare patient,” Dr. Smith said, “and even though we must still code under ICD-10 we are better off than most physicians in this country.”

In his rural Clay County medical practice, Dr. Smith tries to focus on the positive when there is bad news to deliver to patients. For physicians, ICD-10 implementation certainly fits that description. But there is hope, Dr. Smith believes, pointing to medicine’s successes on the state level as not only proof that doctors can be effective advocates for their patients and professions but also to using those successes as a blueprint for future battle plans.

“When you look at the multitude of proposed standards of care, trial lawyer tricks and threats to medicine our Medical Association and its members have fought off over the years, it’s truly remarkable,” he says. “We can succeed, but we all have to be in this together.”

Engaging more doctors and expanding the influence of organized medicine, he says, is the key to learning from the losses we’ve encountered while expanding on our successes. After losses on the Affordable Care Act and now ICD-10, while many in Washington are saying “organized medicine is dead” Dr. Smith believes the opposite is true. He thinks ICD-10 will instead be a turning point where physicians finally stand up and say enough is enough.

“This should be a wake-up call to my colleagues, not just in Alabama but around the nation, that non-physicians are dictating the future of our profession and you can’t afford not to be an advocate for the profession,” he said. “You are most vulnerable to giving up after you’ve suffered a loss – and ICD-10 was a loss for medicine – but we cannot abdicate the remainder of our profession without fighting every inch of the way.”

What You Said…about ICD-10

During the launch of ICD-10 on Oct. 1, we wanted to know how the day was going for our physicians and their staff, so we asked them. Below are a few responses we received about the implementation of the new billing system. Keep in mind the true test of the implementation of ICD-10 won’t be fully realized for some time:

“I think the whole thing is unworkable, a waste of time and will make my office much less efficient. I am not sure why doctors continue to tolerate these ridiculous mandates.”
— Sen. Larry Stutts, M.D., OB/GYN from Sheffield

“Much anticipated arrival of ICD-10 today that passed smoothly for patients and practitioners alike; the final grade is now left with our billing service.”
— Maartin Wybenga, M.D., family physician from Prattville

“We have been working to prepare for years with lots of study, classes and tests. It is disappointing on Day One that 100% of our claims have been rejected. It appears our clearing house is not ready. I’m glad I have put money in a savings account to be prepared. It should be made clear to EVERYONE that we are the only country in the world that uses ICD-10 for payment. It was designed to allow statisticians to monitor disease. This is ALL about Big Brother keeping track of what we do. I am struck by the idiocy of the bureaucrat many years ago that was once reported to say that the expense to doctors would be nothing more than ‘printing’ fees for a few new superbills.”
— Allen Meadows, M.D., allergist from Montgomery

“We had no problems today. We were slower in documentation trying to find the new codes. However, the jury is not in just yet, since we haven’t yet had time for any claims to be rejected. We are cautiously optimistic.”
— Beverly Jordan, M.D., FAAFP, family physician from Enterprise

“Since our EMR did not properly work pulling up the new codes as promised, we had a difficult day searching for codes online, ultimately slowing us down.”
— McCain Ashurst, M.D., OB/GYN from Montgomery

“There’s been a lot of comments about how specific ‪‎ICD-10‬ is, but I have been surprised by how many codes are even less specific than ICD-9.”
— Steven P. Furr, M.D., former president of the Medical Association and family physician from Jackson

“No problems here at all … I took the day off!”
— Tim Stewart, M.D., pediatrician from Huntsville

“Although today was a day I have been dreading for quite some time now, it has gone smoother than I ever expected it to. I believe the transition has gone as well as it has gone because of adequate preparation. My staff, my software vendor and IT support team prepared exceptionally well for the storm. My quick navigation tools were already in place, and my office had several ‘ICD-10 dummy days’ where we practiced entering patients/visits with the new ICD-10 codes. My software vendor also gave us the ability to convert to the new ICD-10 codes effortlessly from our old ICD-9 database. My staff and I also attended seminars by the Medical Association and Baptist Hospital, which helped immensely. As with any storm, your best chance of surviving is to be adequately prepared. We have had this forecast on the radar for quite some time now. For so long it appeared we were blowing a lot of hot air in an attempt to get the hurricane to go away or to change its course as opposed to just hunkering down, preparing, and allowing it to do would it was ultimately going to do. All storms, no matter how bad they are, will eventually blow over. What remains to be seen at this point is how well the change will affect my reimbursements and how much of a delay and additional expenses I will incur.”
— Jefferson Underwood III, M.D., internist from Montgomery

ICD-10 Is Here…Now What?

It’s been just more than a week since the debut of ICD-10, and reports of its implementation have been mixed. While some physicians and their staff had little trouble, others had a very long day of coding issues.

Keeping in mind the true test of ICD-10’s implementation won’t be realized for a few more weeks, we contacted Kim Huey, also known as Kim the Coder, to find out what physicians need to know next about this new billing and coding system:

• Practices will be able to use unspecified codes after this first year IF that is the only appropriate code. There has been much confusion about Medicare’s announcement that claims would not be denied for lack of specificity for the first year. That does not mean unspecified codes will be automatically denied on Oct. 1, 2016. In some cases, you don’t have any other choice. For example, with Vitamin D deficiency, the only options are rickets or unspecified. Obviously, not everyone with Vitamin D deficiency has rickets. Practices should focus on the specificity already documented or on specificity that would support a particular diagnostic test or course of treatment.
• Don’t rely completely on crosswalks built into your EMR. Many of these only take you to the most unspecified code available. Others don’t take into consideration Guidelines and Notes contained within the ICD-10-CM book. Some have chosen not to give their physicians any training – that is a huge mistake! Software simply cannot capture all the nuances in the new codes. For example, COPD with bronchitis with exacerbation is one code in ICD-9-CM. This takes three separate codes in ICD-10-CM. Does the software prompt you to enter the additional codes? EMRs vary widely in their search functions, in which some ask the additional questions necessary to choose the appropriate code, while others simply provide a crosswalk that may or may not be correct. When looking at the differences in coding between ICD-9-CM and ICD-10-CM, a practice needs to look up the code in ICD-10-CM to find the differences in the guidelines. This would not be apparent if just using the crosswalks.
• Everyone who touches a diagnosis code needs some amount of training. Training may vary from just an hour to several hours, whether it is a lab technician or clinical staff or a receptionist who calls in for pre-authorizations.
• There are some good things about the ICD-10-CM changes. Hypertension is no longer classified as benign or malignant. Some conditions, such as asthma can now be coded to capture severity that may support additional treatment or more expensive medications. There is now one code for vaccinations – Z23. There are more specific codes for patient refusal of treatment, underdosing of medication and other circumstances that may affect physician quality reporting.
• Identify the particular challenges in your practice. Coding for injuries is a huge change in ICD-10, but if you don’t see injuries, don’t sweat it. Coding for diabetes is another big change – walk through the coding guidelines to see the differences in information captured. For example, OB practices will now code for the trimester and weeks of gestation – that is almost always documented – and the practice needs to find a way to transfer that to a code on the claim.
• External Codes are not mandated. That is, you do not have to use them unless a particular payer requires it. We have all laughed about the External Cause codes such as burn from fire while on water skis, bitten by a duck, struck by debris from a spacecraft.

In response to a request from the Medical Association, Alabama Medicaid, Blue Cross Blue Shield of Alabama and VIVA HEALTH have said they will not penalize physicians for coding errors under ICD-10 as long as a valid ICD-10 code from the correct “family of codes” is used. This follows a similar policy by CMS for Medicare Part B claims announced in early July.

What You’re Saying about ICD-10, One Month Later

ICD-10 Grace Period Ends Oct. 1