July 20, 2015

On July 6, 2015, the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) jointly announced efforts to help physicians prepare for the October 1st changeover to ICD-10 diagnosis coding.  The AMA and CMS will be offering webinars, on-site training, articles and national conference calls to educate providers and ease the transition throughout the summer.

This announcement makes it seem less likely than ever that there will be a delay in CMS’s implementation of ICD-10 coding.  CMS’s new set of Frequently Asked Questions (FAQs) entitled “CMS and AMA Announce Efforts to Help Providers Get Ready for ICD-10” stated clearly and in boldface type “a valid ICD-10 code will be required on all claims starting on October 1.”  (CMS, of course, does not have the discretion to put off the deadline, for which Congressional action would be required.)  The AMA’s participation in the final set of educational programs and the July 6th AMA Wire post by the organization’s president, “CMS to make ICD-10 transition less disruptive for physicians,” strongly suggest that the organization is shifting its goal from an outright delay to a smoother glide path. 

That glide path is intended to give practices and Medicare contractors time to adapt to the new ICD-10 codes and to work out problems without threat of crippling payment delays or penalties.  It involves the following commitments by CMS, as spelled out in the FAQs:

1. No denials based on specificity of ICD-10 codes.  For a full year from October 1, 2015, Medicare contractors will not deny physician claims “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.”  Nor will Medicare review contractors, e.g., the Recovery Audit Contractors, audit claims as long as the physician submits an ICD-10 code from an appropriate family of codes.
2. No PQRS, VBM, MU penalties based on specificity of ICD-10 codes.  For quality reporting for the year 2015, physicians and other eligible professionals (EPs) using ICD-10 codes from the appropriate family will not be penalized under the Physician Quality Reporting System (PQRS), Value Based Modifier (VBM), or Meaningful Use (MU) programs based on sufficient specificity of the code(s) reported.  EPs will also be exempt from penalties if CMS experiences difficulties in accurately calculating quality scores.
3. Advance payments if Medicare contractors cannot process claims on time.  “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.”  Details on how to apply for an advance payment will be forthcoming.
4. CMS will establish an ICD-10 ombudsman.  An ombudsman will be set up within CMS’ new “communication and collaboration center for monitoring the implementation of ICD-10.”  The ICD-10 ombudsman’s role with be to “help receive and triage physician and provider issues” and to “work closely with representatives in CMS’s regional offices to address physicians’ concerns.”

Underlying the four safeguards above is the expectation that there will be technical problems with the submission and processing of ICD-10 claims.  There will certainly be some, but the issue is less daunting than it was a few months ago.  In the latest round of acknowledgement testing, in which providers voluntarily submit claims with ICD-10 codes to Medicare and receive acknowledgements that their claims were accepted, 1,238 providers participated, submitting more than 13,100 claims.  Nationally, CMS accepted 90 percent of the test claims.  (CMS, ICD-10 Medicare FFS Acknowledgement Testing:  June 1 through 5, 2015.)  Importantly, no claims systems issues were identified during the testing week.  Most of the rejected claims contained errors such as invalid provider identifiers or beneficiary numbers or incorrect dates or zip codes. 

Although the first week of June was the last special CMS acknowledgement week, providers are welcome to submit acknowledgement test claims any time up to October 1, 2015.  (The American Academy of Professional Coders (AAPC) offers a free “ICD-10 Code Translator” where one can enter a current ICD-9 code and see how it maps to one, or multiple ICD-10 codes.)  Readers may also wish to participate in the August 27th CMS National Provider Call “Countdown to ICD-10,” for which they should sign up at MLN Connects Event Registration.

While AMA President Steven J. Stack, MD said in the joint announcement,

We appreciate that CMS is adopting policies to ease the transition to ICD-10 in response to physicians’ concerns that inadvertent coding errors or system glitches during the transition to ICD-10 may result in audits, claims denials, and penalties under various Medicare reporting programs. The actions CMS is initiating today can help to mitigate potential problems. We will continue to work with the administration in the weeks and months ahead to make sure the transition is as smooth as possible,

other organizations including the Medical Group Management Association are still in quest of a legislative solution that would allow parallel tracks or a “grace period” in which both ICD-9 and ICD-10 codes would be accepted.  At least three grace-period bills had been introduced in Congress, and had gained multiple co-sponsors, but were stuck in committee, before Reps. Marsha Blackburn (R-TN) and Tom Price, MD (R-GA)  introduced the Coding Flexibility in Healthcare Act (H.R. 3018) in early July.  This legislation would establish a dual-coding transition period of six months following the October 1st deadline.  H.R. 3018 would also require the Secretary of Health and Human Services to submit a report to Congress assessing the impact of ICD-10 code sets on healthcare providers and other stakeholders no later than 90 days following enactment of the legislation. 

October 1st will be here in less than 90 days.  Practices should be completing training, systems modification and testing by now if they have not already done so.  ABC clients might note that we have been ready for ICD-10 for several months already.  There will not be any more delays.  ICD-9 diagnosis codes will cause claims to be rejected starting October 1st—but a more flexible implementation of the ICD-10 system should help protect cash flow and resolve at least some of the problems that may be encountered.  We hope that all will be settled and functioning smoothly before the Medicare contractors start rejecting claims for lack of specificity in October, 2017.

With best wishes,

Tony Mira
President and CEO