CMS reiterates that it won't reject ICD-10 claims ... sorta

As part of CMS's ICD-10 transition outreach, the agency will appoint an ombudsman to help handle physician and provider issues as they arise.

The partnership announced in early July between the Centers for Medicare and Medicaid Services and the American Medical Association to ease the transition to ICD-10 surprised many people in the healthcare industry, given the AMA's long-standing and vocal opposition to the new medical and diagnostic coding system.

It also appears to have raised a lot of questions. With the October 1 deadline looming, CMS has issued an updated FAQ clarifying its guidance regarding ICD-10 flexibilities.

The first thing CMS makes clear in the FAQ is that there will be no more delays "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," CMS writes.

CMS discusses in some detail what constitutes a valid ICD-10 code under Question 3 of the FAQ. It's far too detailed to reprint here, but Answer 3 elaborates on the circumstances under which the federal agency's previously announced claims amnesty will operate:

"While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, if a valid ICD- 10 code from the right family (of codes) is submitted, Medicare will process and not audit valid ICD-10 codes unless such codes fall into the circumstances described in more detail in Questions 6 & 7."'

[Also: CMS says it won't deny ICD-10 claims for a year]

In Answer 6, CMS elaborates on what, really, is the bottom line regarding ICD-10 amnesty after October 1:

"In certain circumstances, a claim may be denied because the ICD-10 code is not consistent with an applicable policy, such as Local Coverage Determinations or National Coverage Determinations. (See Question 7 for more information about this). This reflects the fact that current automated claims processing edits are not being modified as a result of the guidance. In addition, the ICD-10 code on a claim must be a valid ICD-10 code. If the submitted code is not recognized as a valid code, the claim will be rejected. The physician can resubmit the claims with a valid code."

As part of CMS's ICD-10 transition outreach, the agency will appoint an ombudsman to help handle physician and provider issues as they arise. CMS confirms in the FAQ that the ombudsman will be in place by October 1.

This post first appeared on Revenue Cycle Insights.

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