The Centers for Medicare & Medicaid Services (CMS) has published new frequently asked questions (FAQs) and responses pertaining to guidance regarding ICD-10 flexibilities.
The new questions and responses specifically address expiration of Medicare flexibilities. They are as follows:
Q: When will the Medicare ICD-10 flexibilities expire?
A: The ICD-10 flexibilities expire on October 1, 2016.
Q: Will the ICD-10 flexibilities be extended beyond October 1, 2016?
A: CMS will not extend ICD-10 flexibilities beyond October 1, 2016. There will be no additional flexibility guidance.
Q: Is Medicare going to phase in the requirement to code to the highest level of specificity?
A: No, providers should already be coding to the highest level of specificity. 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 the ICD-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.
Many major insurers did not choose to offer coding flexibility, so many providers are already using specific codes. Please refer to the appropriate coding guidelines.
Q: How do I get ready for the end of flexibilities?
A: Avoid unspecified ICD-10 codes whenever documentation supports a more detailed code. Check the coding on each claim to make sure that it aligns with the clinical documentation.
A complete list of the 2016 ICD-10-CM valid codes and code titles is posted on the CMS website. The codes are listed in tabular order to reflect the ICD-10-CM code book.
Also available is 2017 ICD-10-CM, the updated diagnosis code set for services provided on or after October 1, 2016.
Remember that many major insurers did not offer coding flexibility, so many providers are already using specific codes. Please refer to the appropriate coding guidelines.
A recent survey found that providers made the switch from ICD-9 to ICD-10 with essentially no adverse effects on coding accuracy.
Q: Will unspecified codes be allowed once ICD-10 flexibilities expire?
A: Yes. In ICD-10-CM, unspecified codes have acceptable, even necessary, uses. Information about unspecified codes, including an MLN Matters article and videos, can be found on the CMS website. 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.
When sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code (for example, a diagnosis of pneumonia has been determined but the specific type has not been determined).
For ICD-10 coding resources, visit the Provider Resources section of the CMS ICD-10 website.
Q: What level of ICD-10 code specificity is required so that my claims will not be rejected? How can I ensure my claims will be approved/paid?
A: Even with the ICD-10 flexibilities guidance established by the CMS-AMA Agreement, as of October 1, 2015, a valid ICD-10 code has been required on all claims billed under the Medicare Fee-for-Service Part B physician fee schedule.
A complete list of the 2016 ICD-10-CM valid codes and code titles is posted on the CMS website. The codes are listed in tabular order to reflect the ICD-10-CM code book.
Also available is 2017 ICD-10-CM, the updated diagnosis code set for services provided on or after October 1, 2016.
You should always code to accurately reflect the clinical documentation, and in as much specificity as possible. ICD-10 was implemented in part because of the higher degree of detail that it allows to describe the services you provide.
Avoid unspecified ICD-10 codes when documentation backs up a more detailed code. Check the coding on each claim to make sure that it aligns with the clinical documentation.
Q: If I have questions about how to code correctly using ICD-10, where should I go?
A: For ICD-10 coding resources, visit the Provider Resources section of the CMS ICD-10 website.
Q: How does the end of the ICD-10 flexibilities affect audits that begin after October 1, 2016, but are for claims with dates of service before October 1, 2016?
A: Beginning October 1, 2016, all CMS review contractors are able to use coding specificity as the reason for an audit for a denial of a reviewed claim to the same extent that they did prior to October 1, 2015. Review contractors will notify providers of coding issues they identify during review and of steps needed to correct those issues to the same extent that they did prior to October 1, 2015.
The provider community should code claims to the degree of specificity supported by the encounter and the medical documentation.
Q: Has Medicare updated its NCDs and LCDs to reflect the new ICD-10 codes that take effect on October 1, 2016?
A: CMS and its contractors update the NCDs and LCDs when new codes are added, as was the practice prior to implementation of ICD-10. Codes that affect NCDs will be added at the first opportunity after the codes are finalized.
Of the ICD-10 codes added, 3,549 new codes (97% of the total update) are cardiovascular system codes. Of the new cardiovascular system codes, 3,084 new codes (84% of the total update) resulted from a group of proposals to create unique device values for multiple intraluminal devices and to apply the qualifier bifurcation to multiple root operation tables for all artery body part values.
These codes (84% of the total new codes) do not affect existing NCDs.
Q: Where can I find a list of the ICD-10 codes associated with each NCD and LCD that reflects these updates?
A: Please visit the CMS ICD-10 website for transmittals that contain code updates for NCDs. LCDs can be found in the Medicare Coverage Database, and are searchable in a number of ways, including the “Quick Search” function on the right-hand side of the page.
Q: With the expiration of the ICD-10 flexibilities, is Medicare also prepared to handle and process claims using the new ICD-10 codes that become effective October 1, 2016?
A: As demonstrated by the successful ICD-10 transition, CMS is well equipped to handle changes to codes and to processes, and we do not anticipate any delays.
The annual update to codes is not a new process. Codes were regularly updated on an annual basis until a freeze was established to assist providers and health plans to prepare for ICD-10.
As with previous annual updates to codes, providers should: 1) determine which codes affect their practices, and 2) focus on clinical concepts behind new codes. While this year’s update includes many new codes, the new clinical concepts are minimal. For ICD-10 coding resources, visit the Provider Resources section of the CMS ICD-10 website.
For more information about ICD-10, visit PGM’s ICD-10 overview and ICD-10 crosswalks.