August 31, 2015

CMS Clarifies ICD-10 Flexibility Guidance

The Centers for Medicare and Medicaid Services (CMS) responded to additional questions raised in response to the July 6 CMS/AMA joint guidance regarding ICD-10 flexibility allowed in Medicare’s claims auditing and quality reporting processes.

The clarification provided includes:

  • There is no delay in the implementation of the ICD-10 code set requirement for Medicare or any other organization. Medicare claims with a date of service on or after October 1, 2015, will be rejected if they do not contain a valid ICD-10 code.
  • A “family of codes” is defined as the same as the ICD-10 three-character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition.
  • An Ombudsman will be in place by October 1, 2015 and will work closely with representatives in CMS’s regional offices to address physicians’ concerns.
  • A complete list of the 2016 ICD-10-CM valid codes and code titles is posted on the CMS website. Submitters will know a claim was rejected because it was not a valid code versus a denial for lack of specificity required for a national coverage determination (NCD) or local coverage determination (LCD) or other claim edit.
  • The coding specificity required by NCDs and LCDs does not change. Coverage policies that currently require a specific diagnosis under ICD-9 will continue to require a specific diagnosis under ICD-10.
  • Audit and quality program flexibilities only pertain to post-payment reviews. ICD10 codes with the correct level of specificity will be required for pre-payment reviews and prior authorization requests. 

For more details, please read Clarifying Questions and Answers Related to the July 6,2015 CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities.