July 13, 2015

ICD-10: 12-Months of Flawed Data


Does it seem that the government comes out with major decisions that we in healthcare may not perceive as wise either on a Friday after 5 p.m. or, as in the recent compromise, over a holiday?

I can’t help but think of another Great Compromise, which took place on July 16, 1887, which provided a dual system of congressional representation. The Centers for Medicare & Medicaid Services (CMS) did indicate that, “a valid ICD-10 code will be required on all claims starting October 1, 2015.” At least the dual coding (as suggested by some members of Congress) has been averted thus far.


Last week the United States of America celebrated another Independence Day attributed to its tenacity of follow-through in achieving liberty and never compromising on principle.

Yet, on July 6, CMS caved in to the American Medical Association (AMA) and announced it will not deny claims for a period of 12 months under the Part B physician fee schedule based on ICD-10 wrongly coded claims (as long as a valid code from the right family is used), a decision supported by ICD-10 opponent the AMA. This policy will also be adopted by the Medicare Administrative Contractors (MACs), the Recovery Audit Contractors (RACs), the Zone Program Integrity Contractors (ZPICs), and the Supplemental Medical Review Contractor (SMRC).

The AMA and CMS said they have teamed up to make the transition easier for providers. Both CMS and the AMA plan to conduct a nationwide outreach effort to educate providers through webinars, on-site training, educational articles, and calls to help physicians and other providers get up to speed before the October 1 deadline.

Also available through the CMS website “Road to 10,” which contains a countdown clock and primers for clinical documentation, clinical scenarios, and other specialty-specific resources to help with implementation.

An AMA spokesperson said the change is “a culmination of a vigorous effort by medicine to ask the CMS for a transition period to avoid expected disruptions during this time of tremendous change in the healthcare landscape. This agreement with the CMS is in the best interest of patients and physicians, and in line with the policy set by the nation’s physicians.”  In the announcement the AMA conceded that the implementation deadline would not be changing, a step in the right direction.

CMS said it will also make sure ICD-10 errors don’t trigger penalties (quality reporting completed for program year 2015) for the Physician Quality Reporting System (PQRS), Value Based Modifier (VBM), or Meaningful Use (MU), which tied certain clinical outcomes and processes, like coding, to incentives or penalties.

If the change causes issues for CMS that slows down payment, the federal agency will offer advanced payments to providers. Facilities would receive an advanced partial payment that would have to be paid back. CMS also revealed the hiring of an ICD-10 ombudsman “to help receive and triage physician and provider issues. The Ombudsman will work closely with representatives in CMS’ regional offices to address physicians’ concerns. As we get closer to the October 1, 2015, compliance date, CMS will issue guidance about how to submit issues to the Ombudsman.”

I have been touting for the past three years the benefits of ICD-10, based on the following:

  • Better reflection of advances in medicine and technology
  • Better understanding and tracking of healthcare outcomes
  • Prevention and detecting of fraud and abuse
  • Measure the quality, safety, and efficacy of care
  • Lead effective resource utilization to ensure accurate payment
  • Improve clinical, financial, and administrative performance

On July 8, 2015, CMS released the first proposed update to the physician payment schedule since the repeal of the Sustainable Growth Rate formula (SGR) through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

The proposal includes a number of provisions focused on person-centered care, and continues the transformation of the Medicare program to a system based on quality and healthy outcomes.

So my question is, if CMS is allowing for flawed data to be collected for a 12-month period, how will any of the above be accurately measured?






Denise M. Nash, MD, CCS, CIM

Denise M. Nash, MD, CCS, CIM, serves as vice president of compliance and education for MiraMed Global Services and as such she handles all Compliance and Education needs including migration to ICD-10. She has more than 20 years experience in the healthcare industry. Dr. Nash has worked for CMS in hospital auditing and has expertise in negotiation and implementation of risk contracting for managed care plans. She has also worked with individuals as well as physician groups on utilization and PQRS management to improve financial performance for the risk-based contracts and value based purchasing (VPB) programs. Her past experience also included consulting for the Office of the Inspector General of New Hampshire in its Fraud and Abuse Division.

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