CMS to make ICD-10 transition less disruptive for physicians

Steven J. Stack, MD
Immediate Past President
American Medical Association
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Implementation of the ICD-10 code set is just around the corner, with a hard deadline of Oct. 1. Many physicians have been concerned about adopting this code set because of the heavy investment of time and resources and the potential for claims disruptions that could interfere with patient care.

Fortunately, the AMA has secured provisions that will ease this transition, particularly for physicians in practices with limited resources.

In response to our extensive communication of physicians’ concerns, the Centers for Medicare & Medicaid Services (CMS) announced today that it is making several critical changes to the transition period so that physicians can continue to provide high-quality patient care without risking their livelihood. 

Claim denials

For the first year ICD-10 is in place, Medicare claims will not be denied solely based on the specificity of the diagnosis codes as long as they are from the appropriate family of ICD-10 codes.

This means that Medicare will not deny payment for these unintentional errors as practices become accustomed to ICD-10 coding. In addition, Medicare claims will not be audited based on the specificity of the diagnosis codes as long as they are from the appropriate family of codes. This transition period will give physicians and their practice teams time to get up to speed on the more complicated code set.

Both Medicare Administrative Contractors and Recovery Audit Contractors will be required to follow this policy.

Quality-reporting penalties

Similar to claim denials, CMS will not subject physicians to penalties for the Physician Quality Reporting System, the value-based payment modifier or meaningful use based on the specificity of diagnosis codes as long as they use a code from the correct ICD-10 family of codes.

In addition, penalties will not be applied if CMS experiences difficulties calculating quality scores for these programs as a result of ICD-10 implementation.

Payment disruptions

If Medicare contractors are unable to process claims as a result of problems with ICD-10, CMS will authorize advance payments to physicians.

Navigating transition problems

CMS has said it will establish a communication center to monitor issues and resolve them as quickly as possible. This will include an “ICD-10 ombudsman” devoted to triaging physician issues.

These provisions are a culmination of vigorous efforts to convince the agency of the need for a transition period to avoid financial disruptions during this time of tremendous change. These provisions are a testament to the power of organized medicine and what we can achieve when we band together for the good of our patients and our profession.

What you need to prepare

Although physicians now have a yearlong transition period, now is still the time to buckle down and make sure your practice is as prepared as possible ahead of Oct. 1. Here are several important resources that can help you get ready over the next three months:

  • A special series on payment and coding at AMA Wire® examines what you need to do each month to prepare for the transition, whether you’re an ICD-10 expert or just getting started.
  • The AMA’s ICD-10 Web page offers important information and resources on implementation planning, from cross-walking between ICD-9 and ICD-10 to testing your readiness.
  • CMS also is offering free assistance, including its “Road to 10” website aimed specifically at smaller physician practices. This collection includes primers for clinical documentation, clinical scenarios and other specialty-specific resources to help with implementation. Read more about the agency’s resource offerings.

These significant improvements for the impending ICD-10 roll-out are just one way our collective voice is helping improve our practice environment for greater practice stability and ongoing quality care.

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This is the biggest bunch of BS I have ever seen.<br/> 1. Family of codes? What? <br/> 2. Quality reporting, so how does that work?<br/> 3. So how does the advance payment work?<br/> 4. Yeah, the communication why don't we have that NOW? So we can test NOW? ALL WILLING providers that want to test can test. Even if they go thru a clearinghouse.<br/> <br/> This is a disaster waiting to happen. Why not allow ICD-9 to phase out. Not on / off...Is ANYONE from AMA listening?
I can't disagree that this feels like BS - however, so did DRG's Medicare Part C & D, etc. We docs just want to see patients but we also want to get paid so some system needs to be in place.<br/> <br/> Family of codes means if you submit a claim with diabetes type 2 and is should have been DM 2 with diabetic retinopathy, they are not going to stop payment because you used a less specific code in the "diabetes family".<br/> <br/> Quality reporting has nothing to do with ICD-10. Talk to your business manager.<br/> <br/> Advance payment means they will pay you as they sort out the discrepant claim you submitted rather than withhold payment.<br/> <br/> IT system costs to let "ICD-9" to phase out would double the costs to your practices billing systems. There will be a subtle "phase out" as all claims submitted before Oct 1st will be processed in I- 9 while those submitted on Oct 1st will be processed in I-10. Thus, there will be a year or so phase out of I-9 but you have to pick a switch over date.
Allow me to state that this is a huge win, given that physicians were at risk for being denied reimbursement for ICD-10-CM codes without laterality or other specificities inherent in ICD-10-CM. I hope that CMS directs its Medicaid providers to do the same and that private insurance will follow suit, given that most, if not all, carriers have not published their ICD-10-CM to ICD-9-CM crosswalks that pay fee-for-service claims. <br/> <br/> Allow me to suggest to all that read this is that physicians must pay attention to ICD-10-CM as it affects CMS's physician value-based payment modifier or their transition to the Merit-based Incentive Payment System. CMS will use ICD-10 codes to determine how sick a physician's patient population is, risk adjusting according to the Hierarchical Conditions Categories algorithm. If you don't believe me, call the AMA and ask them yourself.
we are willing to practice and do some trial claims, but it seems there is no clear criteria for that to happen. Who or to "Whom" can we get firm answers?
I am happy that CMS and the AMA have come together in an effort to support the provider community. <br/> <br/> What does this mean for risk adjustment, HEDIS, and STARS where the specificity and coding are essential for supporting patient care through reimbursement?
Has CMS published their definition of a code "family"? Thanks
The joke's on us, and it keeps getting more sophisticated, so that a dreadful, shameful, Pharasitical situation started to appear to be the norm. Oh, well. Life is to be lived forward but understood backward.
ICD-10 is best of the knowledge that can trim the load of treatment over the diseases by coding and classifying them in well shaped manner.The financial factor is a dominent over the tiring and burden work that sometimes overwhelms the physician,so let it favour the process to utlize less manuals.
This is just another "band-aid" on the issue that people are not training and ready to convert. There has been a 6 year time frame to get up to par since the first "whining" session began in 2009 . This just proves people have been procrastinating and not doing what is needed for the transition. CMS has been going through testing for providers, but i can see people are not utilizing that option. What are the complaints going to be in a year when you are STILL not ready? Documentation should have been done the same for ICD-9 as it is for ICD-10 to show the medical necessity and to have continuity of care for patients.
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