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CMS plans to ease transition to ICD-10-CM

According to the AMA, CMS plans to ease transition to ICD-10-CM and ensure that the payment is done. The main issue is the compliance. CMS’s notice states: the Medicare claims processing systems will not have the capability to accept ICD-9 codes for dates of services after September 30, 2015, nor will they be able to accept claims for both ICD-9 and ICD-10 codes. Based on physician’s fears of the transition to ICD-10, the American Medical Association persuaded CMS to enact some changes to the ICD-10 implementation policy so that some of the burden is off physician practices and hospitals. American Medical Association released a joint statement with CMS stating that CMS has agreed to the following changes:

  1. No claims will be denied based on the lack of specificity of the ICD-10 diagnosis code chosen for ONE year. According to the American Medical Association, CMS has agreed to the following:
  • For the first year ICD-10 is in place, there will not be any denial of Medicare claims solely based on the specificity of the diagnosis codes as long as they are from the appropriate code family of ICD-10 codes.
  • The only issue with this is since this is only for one year this can be a set up for denials and compliance issues ahead.
  • Providers must be taught to document and code correctly from the start so as to avoid such situations.
  1. No penalties based on PQRS (Physician Quality Reporting System). According to the American Medical Association release:
  • Physicians will not be subjected to penalties for the Physician Quality Report Systems (PQRS) based on the specificity of diagnosis codes as long as they use a code from the correct ICD-10 family of codes, according to the CMS.
  • Training the staff correctly from the beginning will help in avoiding the penalty.
  1. “CMS will authorize advance payments to physicians”.
  • CMS assures providers that if a Medicare contractor is unable to process claims due to problems with ICD-10, American Medical Association assures that CMS will authorize advance payments to physician.
  • Medicare carriers must have made the transition in regards to their software systems and so there should not be an issue and that CMS has a plan in place in case there are problems.
  1. CMS plans to create an ICD-10 Ombudsman.
  • CMS plans to “establish a communication center to monitor issues and resolve them as quickly as possible” according to the American Medical Association. The ombudsman will be “devoted to sorting out physicians issues”.

It should be clear that CMS is dedicated to helping providers ease into the transition after reading through the changes and are also taking a hard stance in regards to the implementation date of October 1, 2015. As mentioned above, now is the time to learn and understand physician clinical documentation and coding. The transition time can be used as an opportunity to uncover faults in your current system. Time should be allotted and spent for continuous training and auditing. Providers and coders should not choose the unspecified codes.  If there is not enough clinical documentation provided to support the most specific ICD-10 code however it seems to support the unspecified code in the ICD-10 code family, then the unspecified code can be billed. The one year mark will be soon arriving and there won’t be enough time to train providers out of bad habits. “Medicare claims will not be audited based on the specificity of the diagnosis codes as long as they are from the appropriate family of codes”, even though the American Medical Association states that it does not mean there will NOT be any audits.

Ensuring proper training to the providers how the documentation should be specific will aid in reducing the denial of claims.

CMS/AMA Joint Announcement