The recent concessions wrung from the CMS by the American Medical Association and other ICD-10 protesters are no panacea for a smooth transition to the voluminous and complex codes.
It might not even mean the end of the wiggle room to be extracted from the CMS before the Oct. 1 deadline to move to the new family of diagnostic and procedure codes.
But in an unusual joint news release sent out Monday, the CMS and the AMA, its chief antagonist in a years-long fight over ICD-10, have called a truce.
The CMS released a regulatory guidance affording physicians more “flexibility” in using ICD-10 for processing Medicare claims and cutting physicians some slack on ICD-10 use when code discrepancies show up in audits and quality reporting.
The CMS also pledged to create an ICD-10 ombudsman's office to “triage and answer questions about the submission of claims.”
The government held firm on its Oct. 1 deadline, however, and the AMA's official policy opposing the code conversion remains unchanged.
For years, the AMA has led the charge against ICD-10. As recently as during its summer meeting in June, the AMA kept opposition as its gospel, calling the ICD-10 conversion a “looming disaster.”
But with a nod to the inevitable, AMA delegates also issued a policy statement, saying that if postponement of the deadline were impossible, the AMA should push the CMS to adopt “mitigation strategies,” largely drawn from suggestions of members from Alabama and Texas.
Many of the concessions made by the CMS addressed those AMA requests.
In the statement, AMA President Dr. Steven Stack said the CMS actions could “help mitigate potential problems,” while vowing to “work with the administration in the weeks and months ahead to make sure the transition is as smooth as possible.”
Texas Medical Association President Dr. Thomas Garcia, in a separate statement endorsing the CMS/AMA announcement, said, “A giant burden was slightly eased for physicians” with what he described as “an ICD-10 transition grace period.” The Texans, the AMA's largest state society, have been staunch critics of the federal ICD-10 mandate in their own right.
According to the CMS, for one year after Oct. 1, Medicare will not deny physicians or other practitioners Part B claims “based solely on the specificity of the ICD-10 diagnosis code” as long as the provider used a valid code “from the right family.”
The CMS did not provide a spokesman to elaborate on what “family” means in the ICD-10 context.
“This transition period is a responsible solution that marks a win for our health care providers and the patients they care for,” said U.S. Rep. Diane Black (R-Tenn.) who introduced ICD-10 legislation in May that would afford an 18-month grace period from penalties for lack of coding specificity. Black did not say she'd withdraw her bill.
The one-year reprieve from such “granular coding” errors is “a very important step,” said Robert Tennant, senior policy analyst for the Medical Group Management Association.
But, he added, the concession does nothing for “a major group of folks who have not had their software upgraded.”
Those generally smaller physician practices can't put ICD-10 codes in an electronic claim because their practice management systems haven't been updated to the ASC X12 Version 5010 electronic messaging standard needed to handle the longer, more complex ICD-10 codes. Some EHRs also may not be capable of the detailed documentation needed for ICD-10, Tennant said.
As a needed precursor to the ICD-10 conversion, HHS mandated in 2012 a national upgrade from the older, Version 4010 messaging standard, but the switch to 5010 went badly due to delays in vendor software upgrades and provider installations. The CMS twice pushed back its enforcement deadline for 5010 as rejected claims disrupted cash flows to a significant minority of providers nationwide.
Despite the federal mandate, the old 4010 standard is still around, according to a recent survey of MGMA members. About 25% of the respondents said they were still using 4010 to send claims to a clearinghouse at least occasionally. Another 15% were using 4010 to directly submit claims to health plans at least occasionally
“What that tells me,” Tennant said, “there's a pretty significant percentage of providers who'll have no way of generating an ICD-10 coded claim” because they have older practice management systems still sending 4010 messages.
“A lot those folks are relying on their vendors, including their clearinghouses, to massage whatever they send their way,” Tennant said. “Those are the ones that are going to be most vulnerable and won't be covered under this (CMS/AMA) contingency.”
The American Hospital Association, meanwhile, said the leeway on coding errors should be broader “We hope that CMS will give the same protections to hospitals that may need it,” said Linda Fishman, the AHA's senior vice president for public policy analysis and development. “All parties have an obligation to be ready at the same time, including CMS and its contractors.”
Jim Daley, immediate past chairman of the Workgroup for Electronic Data Interchange, a health IT collaborative with members across the healthcare industry, and co-chair for many years of its ICD-10 workgroup, said he was relieved the CMS concessions didn't include approval of so-called “dual coding,” a remedy proposed by some that providers that they be allowed to code in either ICD-9 or ICD-10 for an extended period after Oct. 1.
“That would have been a disaster,” said Daley, who is the IT director for Blue Cross Blue Shield of South Carolina. This Friday WEDI will wrap up the latest of its series of industry surveys on ICD-10 preparedness. This time it has a question that's specifically asks, “Will you be ready” come Oct. 1?
“Most organizations are saying we plan to be ready,” Daley said. “From our earlier surveys, payers and hospitals are on track. Most vendors are on track, but there may be some peripheral vendors that may have some issues.”
Daley said it's an important step that the CMS is working with the AMA to educate physicians about ICD-10. “The more they know, the better they'll be able to use it. That's a good thing for everybody.”