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Published: 14 Sep 2015
The ICD-10 release date is approaching, and with it comes a lot of questions for healthcare organizations: What if the wrong ICD-10 codes are used? What if there are unexpected problems? What happens when a claim is rejected?
Healthcare organizations and physicians may feel overwhelmed as they try to prepare for potential "what if" scenarios with the Oct. 1 transition. One place to turn for guidance is CMS' website, which provides an infographic on how to prepare for ICD-10 release date and a series of FAQs to better answer healthcare IT professionals' concerns.
While not regulations, the FAQs offer a look at how CMS interprets the ICD-10 switchover. Here are some important points made in the FAQs:
Ombudsman in place by Oct. 1
In the first FAQ released, CMS said it will be setting up a communication and collaboration center for monitoring the implementation of ICD-10. The center will include an ombudsman who will handle issues that physicians and providers may have.
"This center will quickly identify and initiate resolution of issues that arise as a result of the transition to ICD-10," CMS stated in its FAQ, adding that the ombudsman will work closely with representatives in CMS's offices to help better address problems.
CMS said that the ombudsman will be in place by Oct. 1. Watch the agency's website for more information on how to submit issues to the ombudsman.
Valid ICD-10 codes
In a clarification published in July, CMS explained the make-up of an ICD-10 code: Valid ICD-10-CM codes are composed of three to seven characters, and codes that have only three characters are part of the ICD-10-CM heading of a category of codes that may be further subdivided for specificity. ICD-10-CM refers to the U.S. clinical modifications of ICD-10 that provide extra details specific to American healthcare.
According to CMS' FAQ, codes with three characters (such as C81, Hodgkin's lymphoma) subdivide into codes with more characters (such as C81.00, nodular lymphocyte predominant Hodgkin lymphoma, unspecified site). C81 by itself is not a valid code.
CMS has published a complete list of valid ICD-10-CM codes on its website.
Submitting an incorrect ICD-10 code
CMS has established a limited grace period for incorrectly submitted ICD-10 codes. For 12 months after the ICD-10 release date, as long as a valid ICD-10 code from the correct family of codes is submitted, Medicare review contractors will not deny it if the specific code is incorrect, CMS said.
However, it is possible that CMS will review a claim for reasons other than lack of specificity of the ICD-10 code.
If a claim is rejected, CMS said the submitter will be informed of the reason why, whether for lack of a valid code or a denial for lack of specificity. Submitters will then have to correct their mistakes and resubmit their claims.
"In certain circumstances, a claim may be denied because the ICD-10 code is not consistent with an applicable policy, such as Local Coverage Determinations or National Coverage Determinations," CMS added in its FAQ. "This reflects the fact that current automated claims processing edits are not being modified as a result of the guidance."
One expert's views about CMS' ICD-10 resources
In health IT expert Robert Tennant opinion, the educational resources that CMS provides -- especially "Road to 10"-- are helpful. However, they won't solve all the problems healthcare organizations will encounter, said Tennant, a senior policy advisor of government affairs at the Medical Group Management Association located in Englewood, Colo. He predicted that the transition to ICD-10 will hit healthcare organizations hard, resulting in a significant drop in productivity and loss of revenue.
Therefore, healthcare organizations will not only have to do more to fully prepare, but Tennant thinks CMS will also have to adjust its ICD-10 transition plan in order to avoid negative results.
"CMS will have to take steps because you cannot grind healthcare in America to a halt just to get more specific diagnosis codes," Tennant said. "So there's going to have to be steps taken, whether it's through Congress or directly through HHS. But I suspect we'll see more announcements from CMS."
Learn more about ICD-10:
WEDI urges action from HHS, foresees unsteady transition to ICD-10
Physician practice worries “a little too high for comfort,” according to a survey