CMS Won’t Deny Incorrect ICD-10 Claims for One Year Following Switch From ICD-9

WASHINGTON, D.C.—As health care professionals prepare for the Oct. 1, 2015, switch from ICD-9 to ICD-10 coding for medical diagnoses, the Centers for Medicare & Medicaid Services (CMS) announced on Monday, July 6, 2015, that it is working with the American Medical Association (AMA) to ease the transition.

Among the additional guidance released that will allow for flexibility in claims auditing and quality reporting, CMS announced that for 12 months after ICD- 10 implementation it will not deny claims billed under the Part B physician fee schedule based solely on the specificity of the ICD-10 diagnosis code as long as the practitioner used a valid code from the right family of codes.

In addition, CMS also announced in the guidance released this week: “For all quality reporting completed for program year 2015, Medicare clinical quality data review contractors will not subject physicians or other Eligible Professionals (EP) to the Physician Quality Reporting System (PQRS), Value Based Modifier (VBM), or Meaningful Use (MU) penalty during primary source verification or auditing related to the additional specificity of the ICD-10 diagnosis code, as long as the physician/EP used a code from the correct family of codes. Furthermore, an EP will not be subjected 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 set up a communication and collaboration center for monitoring the implementation of ICD-10. This center will identify and initiate resolution of issues that arise as a result of the transition to ICD-10. As part of the center, CMS will have an ICD-10 Ombudsman to help receive and triage physician and provider issues. The Ombudsman will work closely with representatives in CMS’s regional offices to address physicians’ concerns.

The International Classification of Diseases, or ICD, is used to standardize codes for medical conditions and procedures. “The medical codes America uses for diagnosis and billing have not been updated in more than 35 years and contain outdated, obsolete terms,” according to the CMS announcement, “The use of ICD-10 should advance public health research and emergency response through detection of disease outbreaks and adverse drug events, as well as support innovative paymen

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