On September 22, the Centers for Medicare and Medicaid Services (CMS) provided additional guidance related to the July 6 ICD-10 flexibilities.
Most notably, CMS named ICD-10 Ombudsman Dr. William Rogers and invited email inquiries to him at ICD10_Ombudsman@cms.hhs.gov.
The following also were clarified:
- The one-year “grace period” is limited to the Medicare Fee-for-Service Part B physician fee schedule. Medicare Advantage will not be affected by the ICD-10 flexibilities, nor will institutional claims or other claim types. Medicare Crossover Claims also will be unaffected.
- While the grace period—which allows for an ICD-10 code from the same family even if the precisely correct code is not chosen—applies to post payment reviews, ICD-10 codes with the correct level of specificity will be required for prepayment reviews and prior authorization requests. Which means contractors conducting medical reviews (Medicare Administrative Contractors (MACs)/Recovery Auditors/Supplemental Medical Review Contractor) will not deny claims solely for the specificity of the ICD-10 code as long as there is no evidence of potential fraud. However, as was previously clarified, the same-family-flexibility is not applicable to prepayment denials because of a National Coverage Determination or a Local Coverage Determination.
- Finally, CMS addressed the issue of advance payment requests in the event that MACs are unable to process claims within established time limits (95% of “clean claims” within 30 calendar days) because of administrative problems. If CMS offers advance payment requests, information will be posted by each MAC and providers would be allowed to submit a single request covering multiple claims. Advance payments are partial payments that must be repaid (likely through recoupment) once claims are adjudicated.
For more information about the CMS guidance on ICD-10 flexibilities, review the recent announcement.
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