Physicians Win One-year Grace Period for ICD-10 Transition

July 07, 2015 04:15 pm News Staff

CMS announced this week that it will provide greater flexibility during the transition to ICD-10 billing codes, easing physicians' trepidation about the move by incorporating several changes that the AAFP urged the agency to adopt(7 page PDF).

[Badge that reads ICD-10 Ready]

When CMS introduced plans for ICD-10, family physicians raised concerns that moving to a new set of codes required additional time for staff training and the possibility of mistakes was too great to implement the codes so quickly. After all, the new system includes more than 68,000 codes -- a far cry from the 13,000 ICD-9 uses. So primary care physicians and others sought an extension to prepare for the transition.

CMS got that message loud and clear, and the agency has taken steps to ensure physicians don't summarily fall victim to claims denials or audits for making innocent mistakes in coding.

"The AAFP applauds CMS for taking actions to ease the transition to ICD-10," said AAFP President Robert Wergin, M.D., of Milford, Neb., in a prepared statement. "Taken together, these provisions will enable family physicians to bill accurately, be paid appropriately and provide continued access to care for patients."

Story highlights
  • CMS has announced a one-year grace period to incorporate changes that primary care physicians and other health professionals sought in implementation of ICD-10 codes.
  • During the grace period, Medicare claims will not be denied and claims will not be audited based on coding as long as the physician submits an ICD-10 code from an appropriate family of codes.
  • ICD-10 increases the number of codes from about 13,000 to more than 68,000.

Rather than imposing the new system according to a drop-dead date, physician practices will have additional time to adjust to the new coding system. During a one-year grace period that begins Oct. 1 -- the date the ICD-10 codes are to be implemented -- Medicare claims will not be denied based on which diagnosis code was selected as long as the physician submits an ICD-10 code from an appropriate family of codes.

Also during the grace period, Medicare claims will not be audited based on the specificity of the diagnosis codes used as long as they are from an appropriate family of codes.

CMS is releasing additional guidance( on flexibility in the auditing and quality reporting process as the medical community gains experience using the new set of codes.

In addition, physicians and allied health professionals who participate in CMS quality programs such as the Physician Quality Reporting System, the value-based payment modifier initiative and/or meaningful use of electronic health records will not be penalized during the 2015 reporting year for failure to select a specific code, as long as they have selected one from an appropriate family of codes. Moreover, practices will not be penalized if CMS encounters trouble in accurately calculating quality scores.

"We have called for additional appeals and agency monitoring for reporting systems that determine appropriate payment for medical services based on quality measures and meaningful use of electronic health records," Wergin said.

Physician practices can receive an upfront payment from Medicare administrative contractors as an option to protect against mistakes that could occur in coding.

"The AAFP urged CMS to expand advance payment options for physicians, which will ensure that physician practices have an adequate revenue flow to maintain financial stability during the transition," Wergin said.

Physicians should be aware that after Sept. 30, Medicare will no longer accept ICD-9 codes for service. Neither will it accept claims using both ICD-9 and ICD-10 codes.

CMS will appoint an ombudsman in each regional office to handle ICD-10 questions, and the agency said it will announce ways to contact the ombudsmen as the October implementation date approaches.

The International Classification of Diseases, or ICD, was developed to standardize codes for medical conditions and procedures. The codes used in the United States have not been updated in more than 35 years and contain outdated terms.

ICD-10 was introduced with the intent of improving public health research and emergency response times by facilitating early detection of disease outbreaks and tracking adverse drug events. The new codes are also meant to support innovative payment models that improve overall quality of care.

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AAFP Fights to Shield FPs from ICD-10 Fallout