July 19, 2015

Efforts Underway to Increase ICD-10 Flexibility for Physician Practices

By Robert M. Tennant, MA

A joint announcement issued on July 6, 2015, by the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) tackled a number of ICD-10 issues in an effort in ease the burden for physician practices transitioning to ICD-10.

While this effort addressed several important issues, at the same time it raised other important questions about the agency’s flexibility message and what practices need to do to avoid catastrophic cashflow disruption.

The announcement focused on four areas:

  • Code Specificity: “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. However, a valid ICD-10 code will be required on all claims starting on Oct. 1, 2015. It is possible a claim could be chosen for review for reasons other than the specificity of the ICD-10 code and the claim would continue to be reviewed for these reasons. This policy will be adopted by the Medicare Administrative Contractors, the Recovery Audit Contractors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor.”
  • Quality Reporting: “For all quality reporting completed for program year 2015 Medicare clinical quality data review contractors will not subject physicians or other Eligible Professionals (EP) to the Physician Quality Reporting System (PQRS), Value Based Modifier (VBM), or Meaningful Use   2 (MU) penalty during primary source verification or auditing related to the additional specificity of the ICD-10 diagnosis code, as long as the physician/EP used a code from the correct family of codes.”
  • Advance Payments: “When the Part B Medicare Contractors are unable to process claims within established time limits because of administrative problems, such as contractor system malfunction or implementation problems, an advance payment may be available.”
  • Communication: “CMS will set up a communication and collaboration center for monitoring the implementation of ICD-10. This center will quickly identify and initiate resolution of issues that arise as a result of the transition to ICD-10. As part of the center, CMS will have an ICD-10 Ombudsman to help receive and triage physician and provider issues.”

The industry is expecting additional guidance from CMS regarding the “flexibility” aspect of the announcement. Most importantly, it is unclear whether this flexibility will apply to claims being submitted or only on the post-adjudication review process. As well, the term “family of codes” is imprecise and needs to be clarified.

Even if less granular diagnosis codes are permitted to be submitted to Medicare, this addresses only one issue. Commercial health plans are not covered under this announcement and each will be making its own business decision regarding code specificity requirements. With physician practices typically having contracts with numerous health plans, there is expected to be considerable uncertainty regarding what code specificity is required by what plans. Practices may not know what the plan policy is regarding ICD-10 codes literally until the claim is rejected.

Further, for practices that have not yet had their practice management system software upgraded or replaced, they may not be able to submit ANY ICD-10 code—even an unspecified one. Most worrisome, MGMA data suggest that as many as one in five practices continue to submit claims using the old Version 4010 format—one that cannot accommodate an ICD-10 code.

If additional flexibility is to come, it may be Congress that takes the lead. Legislation has already been introduced that would permit unspecified codes to be used (HR 2247 and HR 2652). Now Representatives Marsha Blackburn (R-Tenn. ) and Tom Price, MD, (R-Ga.) have introduced the Coding Flexibility in Healthcare Act (HR 3018). This legislation would establish a transition period of 180 days after Oct. 1 for physician group practices and other providers to submit healthcare claims to public or private payers using either ICD-9 or ICD-10 codes. Additionally, HR 3018 would require the Secretary of the Department of Health and Human Services to send a report to Congress, no later than 90 days after enactment of the legislation, assessing the impact of ICD-10 code sets on healthcare providers and other stakeholders.

HR 3018 is not a delay and actually mirrors the six-month “glide path” adopted by CMS for the 2012 transition from Version 4010 to 5010. Those practices that are ready would be permitted to submit ICD-10 codes. It does, however, provide an opportunity for practices who have not had a software upgrade or replacement to continue getting paid. It also will help those practices that believe they are ready to submit ICD-10 codes but have not had the opportunity to conduct external testing.

Should they experience problems with their “go live,” this glide path would allow them to revert back to ICD-9 codes for a short period of time.

Will Congress pass the Code-FLEX act? While that is far from certain, it is clear that CMS needs to explore additional flexibility options to ensure that after Oct. 1, claims continue to be paid so physician practices can continue treating their patients.

About the Author:

Robert Tennant, MA is the director of HIT policy for the Medical Group Management Association.

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