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Friday May 18, 2018

Avoid mistakes when coding for preventive medicine services

Selecting the appropriate code will hopefully facilitate payment for preventive services and reduce some unpleasant questions from patients.

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Posted at 12:00PM May 18, 2018 by Betsy Nicoletti | Comments [0]

Thursday Aug 17, 2017

Are you ready to provide FAA BasicMed exams to pilots?

As of May 1, Congress changed the rules for how the pilots of small private planes may choose to receive medical clearance to fly. Instead of undergoing the full FAA-sanctioned physician exam, certain pilots can get certified by their personal physician.

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Posted at 04:14PM Aug 17, 2017 by Barbara Hays | Comments [0]

Thursday Sep 15, 2016

Grace period for ICD-10 coming to an end

We’ve almost completed a full year of ICD-10-CM use. Congratulations! The world didn’t stop turning on its axis; the sun didn’t explode. Now, we are ready for the next hurdle related to ICD-10: The end of the “grace period” extended by the Centers for Medicare & Medicaid Services (CMS).

What was the “grace period?" It was a 12-month period, beginning Oct. 1, 2015, during which CMS processed and paid any Medicare claim submitted with a valid ICD-10 code that was at least within the family (the first three digits) of the diagnosis in question. This period is ending Sept. 30 of this year, after which CMS and its contractors will require the diagnostic codes you submit to reflect documentation and be specific to the patient and condition.

What codes should you be wary of using? “Unspecified,” “NOS,” and “not otherwise specified” codes will gain particular scrutiny from CMS. These codes will often have the digit “9” as the fourth or sixth character.  

How do you determine if your coding is safe? This answer is a two-parter. First, you need to evaluate which ICD-10 codes you are submitting most often on your claims. When I was in clinic, my family doctors thought they used certain codes often. But after I ran reports to show which ones they actually used, they were often surprised. Running a report of your top 25, 50, or 100 ICD-10 codes will help you determine how often you are using unspecified codes and where you need to concentrate on being more specific. Second, make sure you monitor your Medicare administrative contractor’s Local Coverage Determination (LCD) policies and CMS’s National Coverage Determination (NCD) policies( These polices list the covered diagnoses for specific services you may be performing, ordering or referring. Familiarize yourself with these policies. It will save you and your staff time and heartaches – and maybe a few claim denials, too.

Where can I go to learn more? CMS has published frequently asked questions and other resources about ICD-10(

– Barbie Hays, CPC, CPMA, CPC-I, CEMC, Coding and Compliance Strategist for the American Academy of Family Physicians

Posted at 11:20AM Sep 15, 2016 by David Twiddy | Comments [0]

Thursday Aug 11, 2016

It’s not too early to prepare for diagnosis code changes

Changes are coming to the ICD-10-CM code set. Effective with services provided on or after Oct. 1, ICD-10 diagnosis codes will update to the 2017 version.

The update will affect some of the diagnosis codes used in family medicine. For instance, one of the most significant changes is the addition of a new code, R73.03, for “Prediabetes.” Another example is coding for “familial hypercholesterolemia.” If you had to code that today, you would use E78.0 (Pure hypercholesterolemia). The 2017 version of ICD-10 replaces E78.0 with two new options:

•    E78.00 (Pure hypercholesterolemia, unspecified)
•    E78.01 (Familial hypercholesterolemia)

Similarly, ICD-10 is adding three new codes to report joint pain in the hands:

•    M25.541 (Pain in joints of right hand)
•    M25.542 (Pain in joints of left hand)
•    M25.549 (Pain in joints of unspecified hand)

These are just some of the changes relevant to family medicine. Crosschecking the diagnosis codes you use most often (e.g., the ones listed on your superbill) against the 2017 ICD-10-CM code set would be a good place to start in preparing for the update.

You can access the new ICD-10 code set and other related resources through the Centers for Medicare & Medicaid Services ICD-10 web site( The American Academy of Family Physicians also has ICD-10 resources on its web site, including AAFP Coding Flashcards for 2017.

Diagnosis code changes are coming. Are you ready?

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Posted at 10:56AM Aug 11, 2016 by David Twiddy | Comments [0]

Thursday Mar 03, 2016

You’ve made the switch to ICD-10 coding. Now what?

It’s been more than five months since ICD-10 became the required standard for coding and billing patient encounters in the United States, and the Centers for Medicare & Medicaid Services (CMS) wants to make sure your office is using ICD-10 not just correctly but productively. CMS has released the Next Steps Toolkit(, a free resource that offers specific suggestions and recommendations in these areas:

Assessing your progress. Practices should compare current performance to a pre-ICD-10 baseline or establish a baseline for making future comparisons. Tracking key performance indicators such as rates of rejection and denial is the first step to improvement.

Addressing your findings. Systematically collecting and answering questions from staff and analyzing your clinical documentation and code selection as needed can help head off future problems and fix current ones.

Maintaining your progress. Physicians should make sure their systems capture annual ICD-10 updates, which take place in October.

For more information, visit CMS’s ICD-10 website( and other resources(, including this list of contacts(, by state, for Medicare and Medicaid questions. 

Posted at 04:51PM Mar 03, 2016 by David Twiddy | Comments [0]

Friday Dec 11, 2015

Specialty-specific ICD-10 coding resources available

The Centers for Medicare & Medicaid Services (CMS) has released a new ICD-10 guide, Resources for Specialties and Selected Health Conditions and Services,( aimed at helping physicians and coders properly code common health conditions through ICD-10.

The guide deals with almost two dozen conditions, services, and specialties, including a section devoted to family medicine( Other sections discuss ICD-10 coding for abdominal pain, asthma, cardiology, diabetes, obesity, lab services, and even specific conditions like strep throat and being struck by a vehicle.

The guide is part of CMS’s ICD-10 educational initiative and has direct links to its clinical concept guides(, interactive case studies(, medical case studies(, and webcasts(

Family Practice Management has its own set of ICD-10 coding resources in the FPM Toolbox.

Posted at 10:25AM Dec 11, 2015 by David Twiddy | Comments [0]

Wednesday Nov 04, 2015

Ten percent of claims filed under ICD-10 rejected

One in 10 reimbursement claims filed under the new ICD-10 codes has been denied since the codes became active Oct. 1. But only a fraction of those denials were the result of coding errors.

The Centers for Medicare & Medicaid Services (CMS) recently released statistics from the first 27 days of ICD-10. It said it received 4.6 million claims per day. Of those, 2 percent were rejected for having incomplete or invalid information.

Including an invalid ICD-10 code caused the rejection of 0.09 percent of claims submitted. End-to-end testing conducted earlier this year had estimated 0.17 percent of total claims would be rejected for this reason.

Having an invalid ICD-9 code caused the rejection of 0.11 percent of claims submitted, compared with the expected 0.17 percent, again based on end-to-end testing.

Of all claims processed, 10.1 percent were denied.

CMS and the American Medical Association earlier announced that physicians would have more leeway when filing claims( under ICD-10 in the first year, which may explain the low rejection rate for invalid ICD-10 codes.

The agency said it expects to release more information on the ICD-10 rollout this month. It takes Medicare several days to process claims, and the law requires CMS to wait two weeks before issuing payment. Meanwhile, states can take up to 30 days to process Medicaid claims.

Overall, implementation of ICD-10 has been much smoother than some had expected.

Posted at 04:55PM Nov 04, 2015 by David Twiddy | Comments [0]

Tuesday Oct 27, 2015

A month in, how is ICD-10 doing?

Implementation of ICD-10 will be a month old at the end of this week. On average, that represents about one billing cycle for the typical family medicine practice, so this is a good time to assess the initial impact.

Despite some dire predictions, implementation has not led to mass chaos or brought claims processing to a halt. In fact, preliminary reports suggest implementation is proceeding relatively smoothly. For instance, insurers such as Humana and UnitedHealth Group have reported smooth transitions, according to a report by Forbes( Communications from the Centers for Medicare & Medicaid Services (CMS) suggest things are running equally smoothly on Medicare’s end. Physician complaints about the actual implementation have been sparse to non-existent.

That does not mean that implementation has been universally positive. For instance, there are reports( that coder productivity has dropped between 20 percent and 40 percent. Also, there are anecdotal stories that some payers, including at least one state Medicaid agency, are not paying for “not otherwise specified” codes under ICD-10.

What should you do if you are among those experiencing challenges in implementing ICD-10? CMS suggests that you take the following steps to locate ICD-10 information and contacts quickly:

•    Step 1 Find resources on the CMS ICD-10 website( and Road to 10( online tool.
•    Step 2 Contact your Medicare administrative contractor (MAC)( for Medicare claims questions. Your MAC is your first line for Medicare claims help. MACs cannot respond to questions about Medicaid or commercial health plans.
o    If you have a Medicaid claim question, contact your state Medicaid agency(
      o    If you have a commercial or private health plan claim question, please contact your health plan directly.
      o    The new ICD-10 Resource Guide and Contact List( gives MAC and Medicaid contact info organized by state.
•    Step 3 Contact the ICD-10 Ombudsman for questions. The ICD-10 Ombudsman is an impartial advocate with a dedicated team of experts to answer your questions. Responses will typically be sent within three business days of receipt.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Posted at 11:56AM Oct 27, 2015 by David Twiddy | Comments [0]

Friday Sep 25, 2015

CMS issues more clarification on ICD-10 flexibility

On July 6, the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association released a joint statement( about their efforts to help physicians get ready for the Oct. 1 switch to ICD-10 coding. This statement included guidance from the CMS( that allows for flexibility in the claims auditing and quality reporting processes.

CMS released a series of frequently asked questions and answers about the changes in late July. The agency has now reissued those questions and answers( with revisions to questions 1 and 9, as well as adding nine new questions and answers.

Revised question 1 provides the name and email address for the new ICD-10 ombudsman, William Rogers, MD. Revised question 9 makes it clear that the new flexibility of the ICD-10 Medicare fee-for-service audit and quality program does not extend to any Medicare fee-for-service prior authorization requests. Among the topics addressed in the new questions and answers are:

•    How does the guidance and flexibility relate to Medicare Advantage?
•    How can physicians access advance payments if their Part B Medicare Administrative Contractors are unable to process claims within established time limits because of administrative problems?
•    Will Medicare’s processes change regarding what elements are crossed over to supplemental payers (including commercial payers and state Medicaid agencies)?

Please visit the CMS ICD-10 website( for all of the latest news related to ICD-10 implementation.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Posted at 12:16PM Sep 25, 2015 by David Twiddy | Comments [0]

Tuesday Sep 08, 2015

ICD-10 and workers' compensation

Among the few health care entities not federally required to move to ICD-10 codes starting after Oct. 1 are state workers’ compensation (WC) programs.

That being said, at least 20 states have enacted legislation requiring that their WC programs comply with ICD-10 beginning Oct. 1 anyway. Other states have similar legislation pending or will require ICD-10 codes for specific claim types.

The Workgroup for Electronic Data Interchange (WEDI) has released a chart outlining whether and how each state WC program accepts ICD-10 diagnosis codes( WEDI will regularly update the chart as it receives news from the states. If your state is among those not adopting ICD-10 for WC, you may need to accommodate and maintain dual processing systems, so you can bill both WC for ICD-9 and everyone else for ICD-10.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Posted at 11:59AM Sep 08, 2015 by David Twiddy | Comments [0]

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The views expressed here do not necessarily reflect the opinions of FPM or the AAFP. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. All comments are moderated and will be removed if they violate our Terms of Use.