October 07, 2016

MACs Get Tough on Unspecific ICD 10 Claims

The Centers for Medicare & Medicaid Services (CMS) has informed its Medicare administrative contractors that they will no longer be given the flexibility to submit billing claims with nonspecific ICD-10 disease classification codes when the documentation reflects a higher level of specificity. The new policy was effective Oct. 1, the first anniversary of ICD-10 implementation in the U.S.

All CMS review contractors now are able to use coding specificity as the reason for an audit for a denial of a reviewed claim to the same extent that they did prior to the Oct.1, 2015, ICD-10 implementation date.

Flexibility in submitting claims was allowed during the first year of implementation solely for the purpose of contractors performing medical review so they would not deny claims for the specificity of the ICD-10 code when there was no evidence of fraud. Practices must now code to accurately reflect the clinical documentation and with as much specificity as possible. Medical providers should note that ICD-10 was implemented, in part, because it produces a higher degree of detail than the ICD-9 system it replaced.

Coders should review claims to make sure they align with the clinical documentation. As noted in CMS’ Frequently Asked Questions: Unspecified ICD-10 codes should be avoided whenever documentation supports a more detailed code. (However) …when sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code (for example, a diagnosis of pneumonia has been determined but the specific type has not been determined).

A complete list of CMS’ updated ICD-10 codes for 2017 can be found on the CMS website. Providers should determine which codes affect their practices.

Prior to the Oct. 1, 2016, update, Medicare review contractors did 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 or practitioner used a valid code from the correct family of codes. Codes within a category (same ICD-10 three-character category) are clinically related and provide differences in capturing specific information on the type of condition.

Transmittals that contain national coverage determination updates can be found on the CMS ICD-10 website. Local coverage determination updates can be found in the Medicare Coverage Database.

Previous AIA news coverage offered detailed advice on ICD-10 implementation and a list of useful resources.