CMS recently issued a four-page document with 13 questions and answers related to the July 6, 2015 CMS/AMA joint announcement and guidance regarding ICD-10 flexibility. That announcement, the full details of which can be found here, reiterated that the ICD-10 transition will move forward on October 1, while flexibility regarding denials and payments would apply as long as claims included ICD-10 codes from the correct “family of codes”. CMS has no doubt issued this clarifying Q&A to address lingering confusion in the industry, especially with media outlets calling this an ICD-10 “grace period” – a term CMS was careful not to use. This Q&A clarifies that the announced flexibility applies to Medicare Part B claims only. It only applies for audits and post payment reviews. It also clarifies that the guidance does not indicate any delay in the implementation of ICD-10 for Medicare or other payers. Other questions in the Q&A include, “What is meant by a family of codes?” and “What is a valid ICD-10 code?” (See here for more details.)
Impact for NextGen Healthcare clients: This CMS Q&A should help clarify important details in the original guidance and joint CMS/AMA announcement. Largely due to false and misleading news headlines calling this announcement an ICD-10 “grace period”, the announcement created a lot of confusion in the industry. This Q&A clarifies that there is NO delay in the implementation of ICD-10. The requirement for a family of codes means that you must use a valid ICD-10 code for each diagnosed disease or condition, but you could select the incorrect level of specificity without being penalized in an audit.
Using ICD-9 as an example: a 250 code for diabetes would not be accepted as a valid code, but if you used 250.00 for controlled type II diabetes when you should have used 250.02 for poorly controlled type II diabetes, you would not be penalized. Under ICD-10, the parent category for diabetes is E11 and (similar to the 250 example under ICD-9) they will not accept that code alone. If, however, you used E11.9 for diabetes without complications, when it would have been more appropriate to use E11.65 for diabetes with hyperglycemia, you would not be penalized under the flexibility provisions.