October 23, 2015

ICD-10 Claims Problems Begin to Appear

The first round of claims rejections have arrived following the Oct. 1 implementation of ICD-10.

Some coders are reporting problems with converted local and national coverage determinations (LCDs and NCDs). An LCD for non-invasive abdominal and visceral vascular studies, for example, will not cover unspecified abdominal pain (R10.9), although it will cover abdominal pain of a specified site. What used to be covered in the ICD-9 LCD/NCD no longer meets the medical necessity according to the ICD-10 LCD/NCD. In addition, some payers have noted problems with their edit and audit logic to pay claims.

As reported in the Oct. 10 edition of Advocacy in Action eNews, your Medicare Administrative Contractor (MAC) should be your first stop for Medicare claims help. For answers to Medicaid claim questions, contact your State Medicaid Agency. For commercial or private health plan claim questions, contact your health plan directly. 

If you still need help, contact the ICD-10 ombudsman. He is an impartial advocate who is backed by a dedicated team of experts to answer your questions. You can expect to typically receive responses within three business days.

For LCD issues, the ACR encourages radiology and radiation oncology practices to:

1) closely monitor and compare current ICD-9 LCDs against the converted ICD-10 LCDs that are commonly performed, 2) establish early detection of any potential errors in the ICD-9 to ICD10 translation, 3) trend and monitor your volume of medical necessity and coding related denials, and 4) alert your local Medicare contractor and the ACR in the event an omission or an unexpected denial trend is identified based on the list of approved (i.e., medically necessary) ICD-10 diagnosis codes. In addition, contact the ICD-10 Ombudsman who will work closely with representatives in CMS’s regional offices to address physicians’ concerns. Providers can contact the ICD-10 Ombudsman at ICD10_Ombudsman@cms.hhs.gov and all others should contact the ICD-10 Coordination Center at ICD10@cms.hhs.gov. The ICD-10 Coordination Center in Baltimore will manage and triage issues relating to the ICD-10 conversion. Questions regarding NCDs and LCDs can be addressed to Anita McGlothlin at amcglothlin@acr.org.

The Centers for Medicare & Medicaid Services (CMS) recommends the following to check your claims status:

  1. Interactive Voice Response (IVR): IVR gives providers access to Medicare claims information through a toll-free telephone number. Visit your MAC website for information about the Provider Contact Center and IVR user guide.
  2. Customer Service Representative (CSR): Visit your MAC website for information on the Provider Contact Center only if you are unable to access claims information via IVR.
  3. MAC portal: Visit your MAC website for portal features and access;
  4. Direct Data Entry (DDE): Providers that bill institutional claims are also permitted to submit claims electronically via DDE screens. Visit your MAC website for more information.
  5. ASC X12: The ASC X12 Health Care Claim Status Request and Response (276/277) are a pair of electronic transactions you can use to request the status of claims (via the 276) and receive a response (via the 277). Visit your MAC website for more information.

Remember the following important points when submitting claims:

  •  CMS will ease provider transition to ICD-10 by not denying payment for claims based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner has used a valid code from the right family.
  • A “family of codes” is the same as the ICD-10 three-character category. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity. A three-character code is to be used only if it is not further subdivided.
  • Claims for dates of service after Oct. 1, 2015, will be rejected if they contain both ICD-9 and ICD-10 codes on the same claim form.
  • Local and national coverage policies that require a specific diagnosis under ICD-9 will continue to require a specific diagnosis under ICD-10. Be sure to check local coverage determinations (LCD) and national coverage determinations (NCD) policies to see how they have changed, if they have been deleted or what codes may have been missed in the transition.
  • Unspecified codes are acceptable and sometimes necessary. When documentation or sufficient clinical information does not support a higher level of specificity, unspecified codes are appropriate. It is inappropriate to select a specific code that is not supported by the medical record.
  • The reporting physician is required to provide the clinical documentation necessary for reporting the most specific ICD-10 codes. The ICD-10 code on a claim must be a valid ICD-10 code that contains the full number of characters required for that code.
  • Providers should follow existing procedures for correcting and resubmitting rejected claims and issues related to denied claims. The ICD-10 code on a claim must be a valid ICD-10 code. Providers will know that a claim was rejected because it was not a valid code versus a medical necessity denial for an NCD or LCD or other claim edit.
  • The date of service for outpatient and physician reporting and the date of discharge for inpatient facility reporting determine which code set should be used.
Be sure to check the ACR’s ICD-10-CM Physician Documentation Improvement Training podcasts. These 20 podcasts are designed for radiology physicians and provide information needed to ensure proper documentation for ICD-10-CM diagnosis coding.