The new concessions wrung from the CMS by the American Medical Association and other critics of the mandated Oct. 1, 2015 conversion to ICD-10 are no guarantee of a smooth transition to the complex coding system.
But in an unusual joint news release last week, the CMS and the AMA—its chief antagonist in a years-long fight over ICD-10—called a truce. The CMS released a regulatory guidance stating that for one year after Oct. 1, Medicare will not deny Part B claims from physicians or other practitioners “based solely on the specificity of the ICD-10 diagnosis code,” as long as providers use valid codes “from the right family.”
The agency did not explain what “family” means. 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, however, on its Oct. 1 deadline. And the AMA's official policy opposing the code conversion remains unchanged.
Last week, AMA President Dr. Steven Stack said the CMS actions could “help mitigate potential problems,” while the AMA planned to “work with the administration in the weeks and months ahead to make sure the transition is as smooth as possible.”
The one-year reprieve from “granular coding” errors is a “very important step,” said Robert Tennant, senior policy adviser for the Medical Group Management Association.
But, he added that 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 into an electronic claim because their practice-management systems haven't been updated to the ASC X12 Version 5010 electronic-messaging standard required to handle the longer, more complex ICD-10 codes.
Some electronic health-record systems 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 Version 5010 went badly because of delays in vendor software upgrades and provider installations.
The CMS twice pushed back its enforcement deadline for the 5010 messaging standard as rejected claims disrupted cash flows to a significant minority of providers nationwide.
The old 4010 standard is still around, according to a recent survey of MGMA members. About 25% of survey respondents said they were still using Version 4010 to send claims to a clearinghouse at least occasionally.
“What that tells me,” Tennant said, “is that there's a pretty significant percentage of providers who'll have no way of generating an ICD-10-coded claim. 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 said the federal 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.
Jim Daley, director of information technology risk and compliance for Blue Cross and Blue Shield of South Carolina, said he was relieved the CMS concessions didn't include approval of so-called dual coding, which would allow providers to code in either ICD-9 or ICD-10 for an extended period after Oct. 1.
“That would have been a disaster,” Daley said.