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Experience. Integrity. Advocacy.

CMS Further Clarifies ICD-10 Policies


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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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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