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ICD-10 Flexibilities to end October 1st

After ICD-10 went live on October 1, 2015; CMS (Centers for Medicare and Medicaid Services) allowed a one year grace period for ICD-10 flexibility, to overcome the strong opposition from the AMA (American Medical Association) to ICD-10 implementation. For the one year period, even though a more specific code existed, CMS allowed healthcare providers to submit claims with a valid code from the ICD-10 three character category, without the fear of denial. As per the communication from CMS, claims submitted to Medicaid and Medicare would not be denied as long as healthcare providers used the ICD-10 codes in the correct ‘family’ as related to the treatment. That one year grace period is about to end.

In an update to its FAQ guidelines for the diagnostic code set, CMS said that the one year grace period for ICD-10 coded claims will end on 1st October, 2016. Healthcare providers will now have to submit claims with the correct degree of specificity. According to CMS, “ICD-10 flexibilities were solely for the purpose of contractors performing medical review so that they would not deny claims solely for the specificity of theICD-10 code as long as there is no evidence of fraud. These ICD-10 medical review flexibilities will end on October 1, 2016. As of October 1, 2016, providers will be required to code to accurately reflect the clinical documentation in as much specificity as possible, as per the required coding guidelines.”

CMS will be adding more codes from October 1, 2016 and review contractors will be allowed to deny claims if the levels of specificity are not met. Healthcare providers will have to be certain that their claims do not contain less specific or unspecified codes when there is an appropriate code available for that specified encounter. Any claim with unspecified or less specific codes where a more specific code is applicable, will be denied by the review contractors.

However, healthcare providers need not worry too much – CMS has released clarifying responses to frequently asked questions (FAQs) with regard to the upcoming changes. According to CMS, a number of providers could already be using specific ICD-10 codes. This was because after the implementation of ICD-10, many large private payers had opted out of flexibility rules. However, CMS clarified that unspecified codes can still be used after October 1, 2016; but in specific situations. According to the CMS unspecified codes still have acceptable and necessary uses.

According to the CMS site, “While you should report specific diagnosis codes when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, in some instances signs/symptoms or unspecified codes are the best choice to accurately reflect the health care encounter. You should code each health care encounter to the level of certainty known for that encounter.” This means that healthcare providers can still use unspecified codes post October 1, 2016; in case clinical information is not present to support the diagnosis of certain health encounters with a specific code.

In order to ensure that claims are not denied, CMS has advised healthcare providers with the following:

  • Check the CMS website for the 2016 and 2017 ICD-10 valid codes and code titles lists.
  • Familiarize themselves with the updated diagnosis code sets.
  • Avoid unspecified ICD-10 codes if a more detailed code is available.
  • Check the coding on each claim to ensure that it aligns with the clinical documentation.
  • Identify codes that impact your practice.
  • Concentrate on the clinical concepts behind the new codes.

A large number of healthcare providers do not have to worry about the addition of the new ICD-10 codes as nearly 97% of them are related to the cardiovascular system. However, to ensure their claims are not denied, it is always better to use the services of a professional and dedicated agency. MedConverge’s ICD-10 Code Assist and ICD-10 Resource Hub can help put your healthcare facility on a fast track to a successful ICD-10 transition to the new codes and rules.

Additionally, 84% of the updated codes will not impact the existing national coverage determinations. However, according to CMS, local and national coverage determinations will be added as soon as possible post the finalization of the updated codes. CMS further states that the agency is prepared and will manage the addition of the new codes and rules. As per their answer to the last FAQ, CMS states that it is “well equipped to handle changes to codes and to processes,” and does not envisage any delay in updating the system.

About the Author:MedConverge

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