CMS says it won't deny ICD-10 claims for a year, scores American Medical Association backing

Illustration of an ICD-10 code (HIMSS)

The Centers for Medicare & Medicaid Services on Monday said it will not deny claims under the Part B physician fee schedule based on ICD-10 coding errors, a decision supported by bitter ICD-10 opponent the American Medical Association.

Instead, if a wrong code is used Medicare review contractors will not deny their claim as long as a valid code from the right family is used, CMS said.

ICD-10 is scheduled to take effect on Oct. 1.

The AMA has long blasted the switch in coding over concerns that it would place too many burdens on physicians. 

[Also: AMA chief says US should wait for ICD-11]

However, on Monday, the AMA and CMS decided to team up, a sign that opponents have reserved themselves to the inevitability of the changeover.

In addition to the claim news, CMS said it will also make sure ICD-10 errors don’t trigger penalties for the Physician Quality Reporting System, Value Based Modifier or Meaningful Use, which tied certain clinical outcomes and processes, like coding, to incentives or penalties.

And if the change causes issues for CMS that slows down payment, the federal agency said it will offer advanced payments to providers.

Facilities would receive an advanced partial payment that would have to be paid back.

CMS also said it would hire an ICD-10 ombudsman to manage questions about claims.

Winning them over

The decision by the AMA to play ball with CMS on ICD-10 is a major change for the organization, which has been very outspoken about the change to the new diagnostic coding vocabulary.

Just two months ago, AMA President Steve Stack called for support of a bill to delay the change, and even go as far as to skip ICD-10 and wait a few years for the ICD-11 update.

“We believe the problems associated with ICD-10 are so substantial, our policy is we should not move forward with ICD-10,” Stack told Healthcare Finance.

[Also: ICD-10 bill surfaces, calls for delay]

The new codeset is far more detailed than ICD-9, designed to provide more specific info on types of conditions in the age of electronic health records. But with that comes a major overhaul in how physicians code. While ICD-9 has about 14,000 codes, there will be nearly 70,000 diagnostic codes in ICD-10.

Last year, lawmakers tacked an ICD-10 delay onto legislation, pushing it back for a third time. But when when lawmakers reformed the sustainable growth rate in April they did not mention ICD-10, a move that many thought was an all-clear for the changeover.

[Also: Another ICD-10 bill calls for 2-year grace period]

Still, a few lawmakers have pitched longshot bills since April to delay ICD-10 or soften the blow for physicians.  Rep. Ted Poe, R-Texas, has pitched another delay while a bill by Rep. Diane Black, R-Tennessee, would allow dual coding of ICD-9 and ICD-10 for a period.

Neither of those bills has made it out of committee.

This is a breaking story and will be updated shortly.

Twitter: @SusanMorseHFN