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