AMA to CMS: If you won't dump ICD-10, at least tweak payment policies

The American Medical Association would rather the Centers for Medicare & Medicaid Services got rid of ICD-10 altogether, but in case that doesn’t happen, the organization is urging the government to at least tweak payment policies.

In a seven-page letter sent to Kathleen Sebelius, the secretary of the Department of Health and Human Services laid out its requests.

“We recommend that CMS adopt a policy for Medicare that provides a two-year ‘implementation’ period during which Medicare will not be allowed to deny payment based on the specificity of the ICD-10 code, will provide feedback to the physician on any coding concerns, and will not be allowed to recoup payment due to a lack of ICD-10 specificity,” the AMA wrote.

The heart of that recommendation is the coming transition during which coders, clearinghouses, payers and providers are still learning how to use the codes properly. This period of transition has triggered widespread concern – and the AMA is not the only entity with this worry – that providers and physician practices will face substantive payment disruptions as the industry – including CMS – works out some kinks.

The situation the AMA and its members, and probably all providers and, believe it or not, payers, want to avoid is claims denied because they are not specific enough. That holds up reimbursement, of course, and so the AMA called for “a policy for Medicare that states when the most specific ICD-10 code is submitted by a physician no additional information will be required to adjudicate the claim, particularly in the absence of an attachment standard.”

While HIPAA, in 1996, and more recently, the Affordable Care Act, required a Jan. 1, 2014 deadline for CMS to name a claims attachments standard, the AMA pointed out that that work is on hold until it can be aligned with meaningful use Stage 3. “This is one of the few standards with the potential to bring substantial cost savings directly to physicians,” the AMA wrote. “It is, therefore, incredibly disappointing that physicians will have to wait several more years before they can realize the benefits and the efficiencies that a standard transaction is expected to bring.”

In the meantime, the AMA advocated that physicians in “the most dire of financial situations” should be eligible for advance payments when a physician has submitted claims but is having problems getting the claim to reach the contractor due to problems on the contractor's end; a physician has not been paid for at least 90 days; they attest that at least 25 percent of their patients are Medicare, or they attest that at least 25 percent of their reimbursements are from Medicare. Advanced payments, to be clear, are actually for services already rendered that CMS covers outside the typical reimbursement process, according to the AMA.

While the AMA continues recommending that CMS push back ICD-10 for the time being, the association is pragmatically urging these payment policy changes – presumably to make the transition, if it still must happen this year, as smooth as possible for its members by proactively avoiding those payment disruptions that policy tweaks can address.

This blog is based on a story appearing on Medical Practice Insider.