Medical Billing and Coding Healthcare Blog

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

This guidance raised a number of questions, so CMS has published answers to 13 of the most common.

The FAQs and their answers are as follows:

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

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

2. Q: Does the Guidance mean there is a delay in ICD-10 implementation?

A: No. The CMS/AMA Guidance does not mean there is a delay in the implementation of the ICD-10 code set requirement for Medicare or any other organization. Medicare claims with a date of service on or after October 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 September 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.

3. 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. Many people use the term billable codes to mean valid codes. For example, E10 (Type 1 diabetes mellitus), is a category title that includes a number of specific ICD-10-CM codes for type 1 diabetes. Examples of valid codes within category E10 include E10.21 (Type 1 diabetes mellitus with diabetic nephropathy) which contains five characters and code E10.9 (Type 1 diabetes mellitus without complications) which contains four characters.

A complete list of the 2016 ICD-10-CM valid codes and code titles is posted on the CMS website at The codes are listed in tabular order (the order found in the ICD-10-CM code book). This list should assist providers who are unsure as to whether additional characters are needed, such as the addition of a 7th character in order to arrive at a valid code.

4. 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 that it 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.

5. 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. For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved. Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters. One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid.

6. Q: Does the recent Guidance mean that 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 more information about this). This reflects the fact 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.

7. 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. As stated in the CMS' Guidance, 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.

As such, 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 that 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 at

8. Q: Are technical component (TC) 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.

9. 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-10codes with the correct level of specificity will be required for prepayment reviews and prior authorization requests.


10. 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 October 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.

11. 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 otherpractitioner 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.

12. 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.

Other Payers

13. 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.

For more help with preparing to the transition to ICD-10, use PGM Billing's ICD 10 code conversion tool. You can quickly convert ICD-9 to ICD-10 codes and vice versa by selecting the ICD conversion type followed by a user defined code. The tool now also includes an ICD 10 codes lookup feature that allows user to perform ICD-10 code searches to obtain the correct code and description. Users may search using either the complete or partial ICD-10 code as well as any number of keywords to describe the specified code.

Medicare has disclosed the primary cause for improper payments associated with extracorporeal shock wave lithotripsy (ESWL).

This is according to a recent issue of Medicare Quarterly Provider Compliance Newsletter (pdf), a newsletter from CMS developed to help providers understand the major findings identified by Medicare administrative contractors, recovery auditors and other governmental organizations, such as the Office of Inspector General.

As the newsletter notes, a comprehensive error rate testing (CERT) contractor conducted a special study of Healthcare Common Procedure Coding System (HCPCS) code 50590, lithotripsy (using extracorporeal shock wave) Part B claims submitted from April through June 2014 (Note: The long description for HCPCS code 50590 is Lithotripsy, extracorporeal shock wave).

The contractor found that most improper payments were due to insufficient documentation. There were no claims with medical necessity errors in the special study. When CERT reviews a claim, all lines submitted on the claim undergo complex medical review.

Insufficient documentation means that something was missing from the medical records. For example, CMS notes that the medical record was missing one or more of the following:

  • The correct date of service;
  • Medical records documenting the reason for performing the procedure;
  • Medical records documenting the results of the procedure;
  • A physician’s signature; and/or
  • A signature log or attestation for an illegible signature.

CMS provided the following two examples of improper payments due to insufficient documentation for a lithotripsy and explained what you should do if it happens to you.

1. Missing Records and a Missing Signature

A urologist billed for HCPCS 99218 (initial hospital observation evaluation and management (E&M) service) with modifier -57, and for HCPCS 50590 for a date of service in December 2013. Modifier -57 indicates an E&M service that resulted in the initial decision to perform the surgery.

The submitted documentation included an unsigned operative note for the lithotripsy procedure for the billed date of service. There were no medical records or hospital notes for the initial hospital observation E&M service. After a request for additional documentation, the CERT reviewer received a duplicate unsigned operative report; the provider did not submit a signature attestation or documentation of the E&M service.

This claim was scored as an insufficient documentation error and the Medicare Administrative Contractor (MAC) recouped the payment for both lines on the claim (HCPCS 99218 and HCPCS 50590) from the urologist.

Corrective Action: The urologist can correct the error and retain payment for the lithotripsy by submitting a completed signature attestation, and can retain payment for the E&M by submitting the medical record documentation supporting the E&M level billed. The CERT reviewer accepts late documentation even after the due date. However, CERT will not review documentation received after the due date if an appeal has been initiated.

2. Missing Signatures

A urologist billed for HCPCS 50590 and a cystoscopy with stent insertion (HCPCS 52332) for a date of service in May 2014. The submitted documentation included a pre-procedure consultation report (including history and physical examination, assessment and plan) that was not signed by the urologist. A dictated operative note for the lithotripsy procedure was submitted but it was not signed. Any note or report that is dictated or transcribed but not signed is not valid for Medicare payment.

This claim was scored as an insufficient documentation error and the MAC recouped the payment for both lines on the claim (HCPCS 50590 and HCPCS 52332) from the urologist.

Corrective Actions: Medicare requires providers of all services to sign their records. Providers should not add late signatures to the medical record but instead may submit a signed attestation, such as the one available on the CERT Provider Website. Providers should also submit an attestation if signature(s) are not legible. In order to be considered valid for Medicare medical review purposes, an attestation statement must be signed and dated by the author of the medical record entry, must be for a specific date of service, and must contain sufficient information to identify the beneficiary.

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