Below, you will find clarification regarding ICD-10 flexibilities for post-transition (as scheduled for October 1, 2015) from the Centers for Medicare and Medicaid Services (CMS.)
CMS intended last week’s frequently asked questions (FAQs) on these flexibilities to provide clarification for healthcare organizations and providers. Apparently, two FAQs in particular did not do the trick and themselves required further clarification.
The first iteration of FAQs came in response to the July 6 joint announcement by the American Medical Association (AMA) and CMS that Medicare providers will not have claims rejected for 12 months after the ICD-10 compliance deadline “based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a code from the right family.”
The first clarification concerns what constitutes a valid ICD-10 code:
All claims with dates of service of October 1, 2015 or later must be submitted with a valid ICD-10 code; ICD-9 codes will no longer be accepted for these dates of service. ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity. A three-character code is to be used only if it is not further subdivided. 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 (see question 5) 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.
Many people use the terms “billable codes” and “valid codes” interchangeably. A complete list of the 2016 ICD-10-CM valid codes and code titles is posted on the CMS website, HERE. The codes are listed in tabular order (the order found in the ICD-10-CM code book). This list should assist providers who are unsure as to whether an additional 4th, 5th, 6th or 7th character is
needed. Using this free list of valid codes is straightforward. Providers can practice identifying and using valid codes as part of acknowledgement testing with Medicare, available through September 30, 2015. For more information about acknowledgement testing, contact your Medicare Administrative Contractor, and review the Medicare Learning Network articles on testing, such as SE1501.
CMS has provided a few examples of invalid codes in the update.
Another clarification concerns what constitutes a family of codes:
“Family of codes” is the same as the ICD-10 three-character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved. Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters. One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid.
CMS has offered an additional example for Chrohn’s disease to help provides understand the concept.
The full update is available here.