Last week the Centers for Medicare & Medicaid Services (CMS) announced, in cooperation with the American Medical Association, an agreement not to audit and penalize practices for incorrect ICD-10 coding as long as a valid code in the correct category is reported for one year after ICD-10 goes live on Oct. 1, 2015. CMS also developed a document to answer frequently asked questions; this information can be reviewed online.

 

The CMS policy will require that all characters in the code category be reported. For example, if a code requires a sixth character in the category, the claim must contain the required number of characters. However, this will also allow providers to report unspecified codes in the category. This announcement created a degree of uncertainty in the industry when the AMA and CMS used the term “family of codes,” which is a common term used in CPT coding. I think the language was confusing and certainly caused anxiety among some healthcare providers. Yet I believe that CMS’s point is that each provider must select a code in the appropriate category. If the patient is being treated for congestive heart failure, the provider will select a code from I50 (heart failure) to support a valid code. Keep in mind, though, that CMS will continue to review claims for reasons other than specificity of the diagnosis code.

Allowing a 12-month grace period constitutes good and bad news. The good news is that we have time for physicians to become accustomed to the specificity and the documentation changes necessary to code correctly in ICD-10. It will also allow coders and auditors to monitor providers’ claims internally and audit claims for lack of documentation and specificity. It further will allow us to provide additional education and training to physicians before Medicare audits claims for specificity.

However, the bad news is that providers may think they have a year in which to provide specificity, so they will just select unspecified codes in the category for the conditions they are managing. This will not help documentation or prepare them to assign a more specific code. For example, say the patient has otitis media – will the provider select the code for otitis media, unspecified ear? Or will the provider take the time to select laterality? Many providers will use the 12-month grace period as an excuse not to document or learn the proper coding.   

Also, how many other payors will allow a 12-month grace period? That is a question that has not been answered. Other payors may not do this, so providers need to be prepared to code and document appropriately immediately.

Then on top of this, a bill was introduced in Congress last week to provide a safe-harbor period for the transition to ICD-10. This bill, H.R. 3018 (also known as the Code-Flex Act) would allow a provider to submit claims in both ICD-9 and ICD-10 for a period of six months following the transition. The bill was introduced by U.S. Rep. Marsha Blackburn (R-Tenn.) and Rep. Tom E. Price (R-N.C.).

But how would this work? How can the payor adjudicate claims in both systems? How will the provider select the correct code? Will they just use ICD-9 for six months? CMS has already indicated that it will not be able to accept ICD-9 codes after Sept. 30, 2015. I am certain that at least some other payors will not be able to accept dual coding as well. Hopefully, this bill will not go anywhere. I think it would just cause additional confusion and chaos in the healthcare industry, and could actually delay claims.

I have had physicians ask me, what is the difference if the diagnosis code is incorrect? “I will still get paid, won’t I?” is one refrain I hear. They understand that payment for professional services is determined by the CPT/HCPCS codes and relative value units (RVUs), but what they need to understand is that medical necessity is validated by diagnosis codes, and medical necessity should determine the service they provide to the patient.

My advice is to continue moving forward with your ICD-10 training. It is imperative that the physicians and other providers are well-trained on documentation and coding in ICD-10, specifically for their specialty. For those who use an electronic health record (EHR), it is easy as part of your education and training to show how to select an ICD-10 code in the EHR. I have been doing this, and it answers many of their questions and eases anxiety. Most EHRs that have been upgraded for ICD-10 have test environments in which to practice using ICD-10. As part of the training I provide to physician groups, we actually have an IT staff member start the training by showing them a few of their common diagnoses and how they will look in ICD-10, what search terms to use, and if using IMO, what qualifiers will be available to assist with selecting a more specific code. We also instruct them on how to update and add to their “favorites” list for common conditions they treat routinely. It is also important to explain the coding rules so they understand when they need to report an additional code. Many providers don’t have a complete understanding of the guidelines, which is important if they are doing their own coding. 

Continue to provide support and encouragement to your providers. Many of the providers I train express interest in additional training after ICD-10 is implemented. Education and training should be at a minimum an ongoing process for the first year after ICD-10 is implemented. A simple solution is to provide “lunch and learn” sessions for one hour per month, by specialty. Such training sessions should not be the end, but just the beginning. Continue to audit and monitor patient encounters to ensure that the documentation supports the ICD-10 code selection and that providers are coding to the highest level of specificity. Make certain that you also have a denial management process in place to monitor claims after Oct. 1. These tasks should become an integral part of your operations going forward.

Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner

Deborah Grider has 34 years of industry experience and is a recognized national speaker, consultant, and American Medical Association (AMA) author who has been working with ICD-10 since 1990. She is the author of “Preparing for ICD-10, Making the Transition Manageable,” “Principles of ICD-10,” and the ICD-10 Workbook, among many other publications written for the AMA. She has assisted hospital systems and physician practices in transitioning and understanding ICD-10 for many years. She is a senior healthcare consultant with Karen Zupko & Associates and a clinical documentation improvement practitioner helping physicians improve clinical documentation among all specialties.

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