When you’re more current than Medicare

Sometimes the difference between payment and denial of a claim is having the “right” diagnosis code connected with the service in question. For instance, Medicare has national and local coverage determinations that often list specific ICD-10-CM codes needed to have a service covered — any other diagnosis generates a denial.

The ICD-10-CM codes are updated each Oct^. 1. Unfortunately, Medicare is not as prompt in updating its national coverage determinations (NCDs). The agency has yet to update its NCDs for last October's ICD-10-CM changes.

As a result, you may be experiencing denials because you’re using current ICD-10-CM codes on claims with payments tied to an NCD with outdated ICD-10-CM codes. In these cases Medicare may deny the service as non-covered because the system does not recognize the current ICD-10-CM code as a payable diagnosis. Such denials for non-coverage may leave you or your Medicare patient on the hook for the cost of the service.

What should you do in these situations? One option is to fall back to the old, covered diagnosis codes still on the NCD. This may get the claim paid initially but could generate a recoupment once the NCD is updated. A better approach would be to:

1. Review NCDs that directly affect payment of specific services you provide most often.
2. If an NCD has not been updated with the current ICD-10-CM codes, then hold those claims and check the NCD periodically until you see the ICD-10-CM codes have been updated.
3. Review your denials that may have been driven by an outdated NCD and pend the patient billing on those claims until the NCD has been updated or an appeal has been processed.  

Medicare will eventually get all its NCDs updated to reflect last fall’s ICD-10-CM changes. In the meantime, be aware that the NCDs and ICD-10-CM may be out of sync, resulting in potential denials.

— Carol Self, AAFP Coding and Compliance Strategist; and Kent Moore, Senior Strategist for Physician Payment