Flexible plans for ICD-10 implementation


The launch of ICD-10 on Oct. 1 may result in delays in payment and reduction in productivity. The question is, how much? Until facilities, clinicians, and coders become more facile at using the new codes, software vendors have ironed out their bugs, and payers have developed new medical necessity rules, it is sure to be a bumpy road.

Recognizing that many clinicians would need help with the transition, the Centers for Medicare and Medicaid Services (CMS) will allow for flexibility in the claims auditing and quality reporting processes while the medical community gains experience using the new ICD-10 code set.

On July 6, CMS announced plans to be flexible during the post-implementation phase of ICD-10, and on July 31, the agency issued further clarification about how this flexibility will play out. Flexibility provisions will be in effect for 1 year, through Sept. 30, 2016, and will apply to Medicare Part B fee-for-service claims. Clinicians will continue to use CPT (Current Procedural Terminology) codes to bill for services rendered, and diagnosis codes will continue to support medical necessity just as before. However, using a different diagnostic code set will take time to learn, especially in the beginning.

Here are some suggestions for practices to keep in mind during the early days of using ICD-10.

Code at least to the right “family” for the patient's diagnosis. Provide as much clinical detail as possible to get to a higher level of specificity. Medicare auditors will not penalize for use of nonspecific codes. A valid code, even if not at the most specific level possible, is required. Sometimes this will be a 3-digit code, or sometimes more, as long as it is a valid code.

Prior authorizations and prepayment determinations will have to be coded to the highest level of specificity. If these were provided prior to Oct. 1, payment will be based on the appropriate ICD-9 code using the General Equivalency Mappings, which can be found online.

This flexibility does not apply to Medicaid, either primary or secondary, or to national or local coverage determinations. Coverage policies that currently require a specific diagnosis under ICD-9 will continue to require a specific diagnosis under ICD-10.

For purposes of quality reporting (Physician Quality Reporting System [PQRS], Value-Based Payment Modifier, and Meaningful Use), the same holds true. As long as a valid code is used, the practice will not be penalized. If the clinician met the criteria in terms of numbers submitted, errors based solely on lack of specificity will not result in penalties.

Don't forget about X placeholder characters. Some codes, due to the format, will “skip” a character, using an “X” as a placeholder. For instance, when laterality doesn't apply, there may be an “X” before the character indicating sequelae.

Monitor claims, payments, and productivity carefully over the next few weeks. Learn from mistakes early. Contact vendors and payers as soon as possible to adjudicate problems, and make sure clinicians and staff are receiving adequate training.

For issues that come up related to Medicare claims or denials, or for questions, contact the new ICD-10 ombudsman. Contact information is posted online at CMS or ACP websites.

It is unknown at this time how many or which private payers will exercise similar flexibility, if any. For questions related to billing ICD-10 Medicare fee-for-service claims, consult CMS's Frequently Asked Questions.