The Centers for Medicare & Medicaid will not extend the one-year grace period for ICD-10-coded medical claims, according to recently announced guidelines. An update to its FAQ guidelines for the diagnostic code set noted the ICD-10 flexibilities will expire on Oct. 1, 2016.
“CMS will not extend ICD-10 flexibilities beyond Oct. 1, 2016. There will be no additional flexibility guidance,” the organization presented in a Q&A format.
Is Medicare going to phase in the requirement to code to the highest level of specificity?
No, providers should already be coding to the highest level of specificity. ICD-10 flexibilities were solely for the purpose of contractors performing medical review so that they would not deny claims solely for the specificity of the ICD-10 code as long as there is no evidence of fraud. These ICD-10 medical review flexibilities will end on October 1, 2016. As of Oct. 1, 2016, providers will be required to code to accurately reflect the clinical documentation in as much specificity as possible, as per the required coding guidelines. Many major insurers did not choose to offer coding flexibility, so many providers are already using specific codes. Please refer to the appropriate coding guidelines.
How do I get ready for the end of flexibilities?
Avoid unspecified ICD-10 codes whenever documentation supports a more detailed code. Check the coding on each claim to make sure that it aligns with the clinical documentation.
A complete list of the 2016 ICD-10-CM valid codes and code titles is posted on the CMS website. The codes are listed in tabular order to reflect the ICD-10-CM code book.
Also available is 2017 ICD-10-CM, the updated diagnosis code set for services provided on or after Oct. 1, 2016.
Will unspecified codes be allowed once ICD-10 flexibilities expire?
Yes. In ICD-10-CM, unspecified codes have acceptable, even necessary, uses. Information about unspecified codes, including an MLN Matters article and videos, can be found on the CMS website.
While you should report specific diagnosis codes when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, in some instances signs/symptoms or unspecified codes are the best choice to accurately reflect the health care encounter.
You should code each health care encounter to the level of certainty known for that encounter. When sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code (for example, a diagnosis of pneumonia has been determined but the specific type has not been determined).
How does the end of the ICD-10 flexibilities affect audits that begin after Oct. 1, 2016, but are for claims with dates of service before Oct. 1, 2016?
Beginning Oct. 1, 2016, all CMS review contractors are able to use coding specificity as the reason for an audit for a denial of a reviewed claim to the same extent that they did prior to Oct. 1, 2015.
Review contractors will notify providers of coding issues they identify during review and of steps needed to correct those issues to the same extent that they did prior to Oct. 1, 2015.
The provider community should code claims to the degree of specificity supported by the encounter and the medical documentation.
With the expiration of the ICD-10 flexibilities, is Medicare also prepared to handle and process claims using the new ICD-10 codes that become effective Oct. 1, 2016?
As demonstrated by the successful ICD-10 transition, CMS is well equipped to handle changes to codes and to processes, and we do not anticipate any delays.
The annual update to codes is not a new process. Codes were regularly updated on an annual basis until a freeze was established to assist providers and health plans to prepare for ICD-10.
As with previous annual updates to codes, providers should: 1) determine which codes affect their practices, and 2) focus on clinical concepts behind new codes. While this year’s update includes many new codes, the new clinical concepts are minimal.