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Updated on: November 28, 2016

CMS Draws Up “Just in Case” Contingency Plans for ICD-10 Scenarios

Original story posted on: October 7, 2015

The Centers for Medicare & Medicaid Services (CMS) is monitoring the progress America’s healthcare industry is making with the implementation of ICD-10 – but it’s also standing by with a series of contingency plans should there be any significant disruption.


In its document, “Medicare Fee-For-Service Claims Processing Contingency Plan for ICD-10 Implementation,” CMS envisions five possible scenarios, drawing up corresponding actions the agency anticipates taking in the event that Medicare Fee-For-Service (FFS) claims are not being processed correctly. CMS was quick to point out, however, that “under no scenario would it (CMS) be able to allow for dual processing.” 

In the meantime, CMS says it will be monitoring progress being made for the next 30 days to determine whether to pull the trigger on its contingency plans. By law, all HIPAA-covered entities must use ICD-10 when submitting claims with dates of service of Oct. 1, 2015 and later. CMS also indicated that it may need to work with Medicare Administrative Contractors (MACs) and data centers if its workload includes a large number of claims that have been held for processing or need to be reprocessed. 

Scenario 1: Industry System Failures 

In this scenario, CMS projects Medicare FFS systems are working as expected, but providers can’t submit any ICD-10 codes as required. In this case, CMS is prepared to trigger what it describes as an “educational blitz,” reminding submitters of “options and tools available for ICD-10 readiness.” 

Scenario 2: Industry Failure to Submit Correct ICD-10 Codes

In its second “what-if” scenario, providers are submitting incorrect codes and claims are being appropriately denied. In this case, the agency will be prepared to offer additional education through MLN Matters articles, fact sheets, tools, and booklets. 

Scenario 3: CMS System Failures

Under the third scenario, Medicare FFS systems are not working as expected and there are large numbers of either rejected claims or denials due to internal (CMS) ICD-10-related system issues. In this scenario, CMS noted that ICD-10 will continue to be required on all FFS claims and that the agency must resolve whatever issues have been identified. 

In this case, CMS also reported that it will implement a “claims hold” after the claims have been entered into the system, or the front end, but not prior to front-end processing – acknowledging that it has no experience holding claims in this manner. CMS is clear in its guidance when it says that “holding claims prior to front-end processing is therefore not recommended.”

The claims hold would be in effect as operational issues are being assessed. Also under this scenario, CMS is prepared to invoke the Emergency Response Team (ERT) to determine the appropriate actions.

Scenario 4: Delay in Implementing ICD-10 

Here, CMS indicates that there will be an additional delay in the implementation of ICD-10 and that the agency will continue processing ICD-9 claims after Oct. 1, 2015.

Scenario 5: Medicare FFS System Problems Not Related to ICD-10 

In this worst-case scenario, there are problems with the FFS claims processing systems release unrelated to ICD-10 implementation, with the agency recognizing that the “industry blames issues on ICD-10 implementation” – although ICD-10 would still be required.



Read the Contingency Plan

Chuck Buck

Chuck Buck is the publisher of ICD10monitor and is the executive producer and program host of Talk Ten Tuesdays.

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