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Part B Insider (Multispecialty) Coding Alert


CMS: For First Year, We Won't Deny Claims With Wrong ICD-10 Codes

As long as you use an ICD-10 code from the right “family,” the MAC will pay your claim.

For months, it seemed like the AMA and CMS would be at odds over ICD-10—while the medical association wanted a delay, CMS was steadfast in its insistence that implementation would take place on Oct. 1. Fortunately, the two groups joined forces in the best way possible this week, not only partnering to provide resources to the community, but making concessions in claims acceptance that will please everyone.

The scoop: On July 6, CMS and the AMA announced that they’ve forged a partnership to help practices during the final three months before ICD-10 implementation in response to urging from the provider community. As a result, the two groups released guidance that included four important questions and answers, as follows:

1. You’ll have access to an ombudsman and a communications center. CMS is anticipating issues and questions during the ICD-10 transition, and is therefore creating a “communication and collaboration center” as well as appointing an ICD-10 ombudsman to resolve issues and address concerns. “As we get closer to the Oct. 1, 2015 compliance date, CMS will issue guidance about how to submit issues to the Ombudsman,” CMS said in the guidance.

2. Incorrect ICD-10 codes won’t automatically trigger denials. If you use the wrong ICD-10 code within the first year after Oct. 1, your claim will still be processed and paid, as long as you use an ICD-10 code from the correct code group, CMS says. 

In black and white: “While diagnosis coding to the correct level of specificity is the goal for all claims, 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…based solely on the specificity of the ICD-10 diagnosis code, as long as the physician/practitioner uses a valid code from the right family,” CMS says in the guidance.

Keep in mind, however, that this doesn’t let you off the hook completely—you still have to use a valid ICD-10 code on your claim and it has to be from the correct code family. In addition, your claim could still be denied for other reasons besides the ICD-10 code’s specificity.

3. If you use the wrong ICD-10 code for quality reporting, you won’t face penalties. Whether you’re reporting for PQRS, value-based modifiers (VBM) or meaningful use (MU), no penalties will apply as long as you use an ICD-10 code from the right code family.

“An eligible professional (EP) will not be subjected to a penalty if CMS experiences difficulty calculating the quality scores for PQRS, VBM or MU due to the transition to ICD-10 codes,” CMS added.

4. You could be entitled to an advance payment if your MAC faces “administrative problems.” If your MAC experiences a system malfunction or has trouble implementing ICD-10, you might be able to collect a conditional partial payment until the issues are resolved.

The advance payments—which require repayment—do not apply if the physician is unable to submit a valid claim for services rendered, CMS clarifies. However, if a Medicare systems issue interferes with claims processing, CMS and the MACs will post information on how you can request an advance payment.

CMS, AMA Look Ahead

Although the four new ICD-10 clarifications may not answer all of your questions about the transition, they should certainly help practices feel better about the approaching implementation date.

“We appreciate that CMS is adopting policies to ease the transition to ICD-10 in response to physicians’ concerns that inadvertent coding errors or system glitches during the transition to ICD-10 may result in audits, claims denials, and penalties under various Medicare reporting programs,” said AMA President Steven J. Stack, MD in a July 6 statement. “We will continue to work with the administration in the weeks and months ahead to make sure the transition is as smooth as possible.”

Resource: To read the CMS/AMA guidance, visit