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CMS won't deny ICD-10 claims for a year

July 7, 2015
by Rajiv Leventhal
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Nationally, the Centers for Medicare & Medicaid Services (CMS) accepted 90 percent of claims from the more than 1,200 submitters who participated during CMS’ third round of ICD-10 end-to-end testing.

This round of testing took place between June 1-5. During the first ICD-10 end-to-end testing week, which took place from January 26 until February 3, 81 percent of claims were accepted; on June 2, the agency announced that 88 percent of submitted claims were accepted in the second round of testing,  which took place from April 27-May 1.

No Medicare fee-for-service claims systems issues were identified during this testing week or the previous acknowledgement testing weeks, CMS said. In the June test, as in previous acknowledgement testing weeks, CMS found that most rejects resulted from improperly developed test claims unrelated to ICD-10. The agency said, “Most rejects were the result of provider submission errors in the testing environment that would not occur when actual claims are submitted for processing. CMS will continue to conduct extensive outreach to testers on setup of test claims to avoid these issues for providers who plan to acknowledgement test.”

After CMS announced the first round of testing results, nearly 100 physician groups representing state and specialty medical societies wrote a letter to the agency expressing their remaining ICD-10 concerns as well as voicing displeasure with the first round of results, despite CMS’ praise.

Additionally, CMS has announced a joint effort with the American Medical Association (AMA) to help physicians get ready ahead of the Oct. 1 deadline. In response to requests from the provider community, CMS is releasing additional guidance that will aim to allow for flexibility in the claims auditing and quality reporting process as the medical community gains experience using the new ICD- 10 code set.

In that guidance includes:

  • 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 through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family. However, a valid ICD-10 code will be required on all claims starting on October 1, 2015. It is possible a claim could be chosen for review for reasons other than the specificity of the ICD-10 code and the claim would continue to be reviewed for these reasons.
  • CMS will have an ICD-10 Ombudsman to help receive and triage physician and provider issues. The Ombudsman will work closely with representatives in CMS’s regional offices to address physicians’ concerns.

Rajiv Leventhal is Associate Editor of our sister-brand, Healthcare Informatics.