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How to get ready for ICD-10?

How to get ready for ICD-10?
30 September 2015

 Here are answers to questions that may arise after the transition to ICD-10.

  1. What if a provider has a problem due to the transition to ICD-10 after October 1, 2015?

CMS knows that migrating to ICD-10 would be a challenge to medical practices. Therefore CMS is set to implement a communication and collaboration center to monitor the performance of ICD-10. If a provider encounters a problem, this center will immediately identify and provide solution for issues that arise after the transition to ICD-10. In addition to this center, CMS will employ an Ombudsman to receive and triage provider and physician issues. Physician concerns will be addressed by the Ombudsman by working with the representatives in the regional offices of CMS and CMS will issue guidance on how to submit problems to the Ombudsman.

  1. Will a claim be denied if a provider uses the wrong ICD-10 code?

It is the norm that medical practices must use the correct diagnosis code for claims. However Medicare review contractors will not deny claims billed by physicians and practitioners for one year from the implementation of ICD-10, when the bill is as per Part B physician fee schedule, and it is received through automated medical review or complex medical record review based exclusively on the specificity of ICD-10 diagnosis code, if the practitioner / physician has used a valid code from the right family of codes.

Though the above exemption is available for one year, a valid ICD-10 is required for all claims from October 1, 2015. A claim could also be reviewed for reasons other than the specificity of ICD-10 code for reasons mentioned above. This measure will be executed by the Recovery Audit Contractors, Medicare Administrative Contractors, Supplemental Medical Review Contractors and the Zone Program Integrity Contractors.

  1. What would happen if an incorrect ICD-10 code is used for quality reporting? Will Medicare reject an informal review request?

Medicare clinical quality data review contractors will not require Eligible Professionals (EP) or Physicians to report to PQRS (Physicians Quality Reporting System), MU (Meaningful Use 2) or VBM (Value Based Modifier) if the quality reporting is already completed for the program year 2015. In this case physicians and EP are exempted from penalty. This exemption is given while auditing or primary source verification is carried out on the additional specificity of the ICD-10 diagnosis code and the EP or physician has used a code from the right family of codes.

An EP need not incur penalty if it is difficult for CMS to calculate the quality scores for VBM, PQRS or MU due to the transition to ICD-10 codes. Informal review requests for quality will not be denied if the EP has submitted required number / type of measures / domains on the specified percentage / number of patients and if the only error is related to the specificity of the ICD-10 code and the physician or EP has used codes from the right family of codes. In these cases, CMS will monitor the implementation of ICD-10 and adjust the timeframe if required.

  1. What is advanced payment? How can I avail this facility?

When claims are not processed within the time limit by Part B Medicare Contractors due to administrative problems such as implementation problems or contractor system malfunction, there is an option to apply for advance payment. It is a conditional part payment and it has to be repaid. Advance payment is made when the conditions mentioned in CMS regulation at 42 CFR Section 421.214 are met. The Medicare supplier/physician must apply for advance payment by submitting a request to the concerned MAC (Medicare Administrative Contractor). If there is a problem in the Medicare systems that process claims, MAC and CMS will post details about how to apply for advance payments. However, CMS is not authorized to give advance payment when a physician is unable to request a valid claim for medical services given.