Clarifying Questions and Answers Related to the July 6, 2015 CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities
JPR: The information below is from the Medicare document above.
As stated in the CMS’ Guidance, 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 of codes. However, they are subject to specific LCD or NCD requirements.
JPR: I can think of few unspecified eye codes: ARMD, ectropion, scleritis, or amblyopia that would cause a denial. Most LCD’s for Eyecare include ranges of codes and do not exclude the “unspecified code.” As a certified coder, I am taught that the most specific codes and the group of codes that most accurately reflect the encounter, based on coding guidelines is the proper way to report the service.
For one, unspecific codes inform the world that the provider “does not know what is wrong with the patient.” Both the clinic manager and the provider should want to avoid this impression. While most won’t be able to be in the top ten-percent of clinics in terms of coding accuracy–you don’t want to be in the bottom 50% and certainly not the bottom 10-percent. Being specific, accurate, and following all coding guidelines is the best strategy to get paid, every time, and in all situations, by all carriers. Lastly, if the providers ever wanted to practice medicine because they wanted to help people, here is their opportunity. We need the specificity and additional status codes for research. Universities worldwide are waiting on more specific data to help prevent and cure diseases. As I stated earlier, improve your diagnosis reporting because it’s the right thing to do.
In another example, a patient has a diagnosis of G43.711 (Chronic migraine without aura, intractable, with status migrainosus). Use of the valid codes G43.701 (Chronic migraine without aura) or G43.719 (Chronic migraine without aura, intractable without status migrainosus) instead of the correct code, G43.711, would not be cause for an audit under the audit flexibilities occurring for 12 months after ICD-10 implementation, since they are all in the same family of codes.
JPR: Most in Eyecare use the unspecific headache codes. I recommend, in my ICD-10 training that the provider report the headache more specifically as tension, migraine, ocular, retinal, etc…There is no way for the carrier to know which type of migraine the patient has and the auditor would actually have to review the notes and compare them to the specific code reported. Not all auditors do this so this would be a rare phenomenon.
Question 4: What should I do if my claim is rejected? Will I know whether it was rejected because it is not a valid code versus denied due to a lack of specificity required for a NCD or LCD or other claim edit?
Answer 4: Yes, submitters will know that it was rejected because it was not a valid code versus a denial for lack of specificity required for a NCD or LCD or other claim edit. Submitters should follow existing procedures for correcting and resubmitting rejected claims and issues related to denied claims.
Question 5: What is meant by a family of codes? (Revised 7/31/15)
Answer 5: “Family of codes” is 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. For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved. Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters.
One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid.
The three official CMS documents are available to download below: