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Lisa Trundy, CPA

New CMS and AMA Guidance Offers Flexibility in Claims Auditing and Quality Reporting Process After October 1, 2015, ICD-10 Compliance Deadline


With fewer than 80 days remaining until providers must switch from ICD-9 to ICD-10 coding for medical diagnoses and inpatient hospital procedures, the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) announced new guidance to help physicians get ready ahead of the October 1, 2015, deadline.

CMS detailed the following guidance, which affects Medicare Part B (fee-for-service) claims:

  • For one year after the October 1, 2015, implementation deadline, Medicare claims will not be denied based on the specificity of the ICD-10 diagnosis codes provided, as long as the physician submitted an ICD-10 code from an appropriate family of codes. 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 policy will be followed by Medicare Administrative Contractors and Recovery Audit Contractors.
  • To avoid potential problems with mid-year coding changes in CMS quality programs (PQRS, Value-Based Modifier, and Meaningful Use) for the 2015 reporting year, physicians using the appropriate family of diagnosis codes will not be subject to a penalty if CMS experiences difficulty calculating the quality scores for PQRS, VBM, or MU due to the transition to ICD-10 codes. CMS will continue to monitor implementation and will adjust the duration if needed.
  • CMS intends to create a communication center which will include an ICD-10 ombudsman to help receive and triage physician and provider problems that need to be resolved during the transition. The ombudsman will work closely with representatives in CMS’ regional offices to address physicians’ concerns.
  • CMS will authorize advanced payments if Medicare Part B contractors are unable to process claims within established time limits due to administrative problems with ICD-10 implementation.

The Medicare claims processing systems will not have the capability to accept ICD-9 codes for dates of services after Sept. 30, 2015, nor will they be able to accept claims for both ICD-9 and ICD-10 codes.

This guidance will allow for flexibility in the claims auditing and quality reporting process as the medical community gains experience using the new ICD- 10 code set.