A year after ICD-10 implementation, the Centers for Medicare and Medicaid Services (CMS) has confirmed that the one-year grace period, announced jointly with the American Medical Association (AMA) in July 2015, will expire on October 1, 2016.
The grace period allowed providers to submit ICD-10 codes in the same “family” even if the codes selected were not as specific as possible. Based on questions and answers provided by CMS on August 18, 2016, the grace period will expire and no further flexibilities will be provided. For year two of ICD-10, providers should choose codes that reflect the highest level of specificity available or risk denials.
What does that mean for providers? Not much, according to CMS, which said most providers already are coding to the appropriate specificity, in part because many commercial payers did not offer the same flexibilities that CMS did.
Also, unspecified codes are still allowed. According to CMS, unspecified codes “have acceptable, even necessary, uses.”
Still, the end of the grace period may leave some providers scrambling to be sure they are correctly coding claims. What should you do? Here are five suggestions for surviving the end of the ICD-10 Grace Period.
Don’t panic.
You’ve got this. The big transition happened a year ago, and look how well that went. The end of the grace period might mean a few more denials, or it might not. Either way, don’t panic.
Code to the highest specificity possible.
As mentioned above, unspecified codes are still available and often are the valid choice. But if the documentation supports a code with a higher level of specificity, then that’s the code that should be chosen.
In an interview with ICD-10 Monitor, senior healthcare consultant Laurie Johnson said CMS is not as concerned with whether or not an unspecified code is used, but whether it reflects the clinical record. “Reviewers will be evaluating if the code matches the specificity in the clinical documentation,” Johnson warns.
Here’s what CMS advises:
While you should report specific diagnosis codes when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, in some instances signs/symptoms or unspecified codes are the best choice to accurately reflect the healthcare encounter. … When sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code (for example, a diagnosis of pneumonia has been determined but the specific type has not been determined).
Continue educating coders and providers.
“This announcement from CMS highlights the importance of continuing ICD-10-CM education as well as clinical documentation improvement,” says Johnson.
Internal audits provide a good basis for revealing areas of weakness in your coders and providers. Also, keep monitoring denials and requests for more information from government and commercial payers to learn where better documentation or more specific code selections will generate cleaner claims. Then, use that information to inform your education and training program.
Stay current with code updates.
In August, updates to the ICD-10-CM and ICD-10-PCS code sets were released for the first time following a partial code freeze that began in 2011. Those updates, which will be effective October 1, 2016, are available for download on CMS’ 2017 ICD-10-CM and GEMs and 2017 ICD-10-PCS and GEMs webpages.
The recently released 2017 Inpatient Prospective Payment System (IPPS) final rule also includes many changes to ICD-10. Allen Frady, RN, BSN, CCS, CCDS, outlines some of those changes in a recent ICD-10 Monitor article called, “Ten Things about Oct. 1 that Coders and CDI Specialists Need to Know Now!”
Finally, CMS and its contractors regularly update National and Local Coverage Determinations (NCDs and LCDs) when new ICD-10 codes are added. Be sure you are using the most updated NCDs and LCDs for coding and billing.
Monitor your denials.
Remember, the ICD-10 flexibilities really affected only post-payment medical reviews and prevented review contractors from denying claims solely based on ICD-10 specificity.
Beginning October 1, 2016, CMS review contractors will once again have “coding specificity” in their arsenal of reasons for a denial just as they did prior to October 1, 2015. Review contractors will notify providers of any coding issues and provide the steps needed to correct those issues just as they did previously.
Just as with the ICD-10 implementation itself, the end of the CMS grace period may cause some providers to worry. But by following a few simple steps, you and your practice can experience another successful ICD-10 transition.
For more information about the end of the ICD-10 grace period, review CMS’s Clarifying Questions and Answers Related to the July 6, 2015, CMS/AMA JointAnnouncement and Guidance Regarding ICD-10 Flexibilities document.
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