CMS has indicated that for one year following the October 1, 2015, ICD-10
implementation date, CMS contractors will not deny claims based solely on the specificity of the ICD-10
diagnosis code as long as the physician used a valid code from the right “family of codes.”
What is a code family?
The Centers for Medicare & Medicaid Services (CMS) has clarified that “family of codes” is the same as the ICD-10 three-character category. For example, category H25
(age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved, such as: H25.031 (anterior subcapsular polar age-related cataract, right eye); H25.22 (age-related cataract, morgagnian type, left eye); and H25.9 (unspecified age-related cataract). All of these codes are in the H25 family. However, it’s important to note that simply reporting H25 would not be sufficient. H25 is not a billable diagnosis code.
Even with the added flexibility that CMS has provided for reporting ICD-10 codes, I’m still concerned about the
transition. How will I know if a claim was denied based on whether it was invalid or whether it was not specific enough?
CMS has indicated that contractors will make clear when a claim is denied due to an invalid code versus a denial for
lack of specificity required. If a claim is rejected because an invalid code was used, the claim should be resubmitted with a valid code.
Does the CMS leeway with regard to ICD-10 code submission specificity apply to all insurance companies?
No. The guidance from CMS only applies to claims billed under the Medicare Fee-for-Service Part B physician fee schedule. Commercial payers will determine whether they will allow any leeway in ICD-10 code reporting. Additionally, this flexibility outlined by CMS does not apply to claims submitted for beneficiaries with Medicaid coverage, either primary or secondary.
Ask the experts
AOA’s Coding Experts are available to answer questions about ICD-10 and other coding topics through the online form available at aoa.org/ask-the-coding-experts.