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Archive July 2016 XVII, No. 7

Coding & Billing: ICD-10 Grace Period Is Nearly Over

Come October, you can expect to see a resurgence in claim denials.

Cristina Bentin

Cristina Bentin, CCS-P, CPC-H, CMA



When CMS finally rolled out ICD-10 last October after repeated delays, the new code set wasn't nearly as catastrophic as some had forecast. Rather than a complete meltdown of claims processing, denials were relatively few, usually due to either invalid code selections or valid diagnoses previously covered in ICD-9 that were wrongly considered to not meet medical necessity requirements under ICD-10. Now that we're several months into ICD-10, you may be breathing a sigh of relief, thinking you're over the hump. Not so fast. We're starting to see a resurgence in denials. This uptick is likely because CMS and other carriers are beginning to apply more stringent edits when adjudicating claims.

Close enough no longer good enough
If you remember, when ICD-10 was first implemented, CMS in collaboration with the American Medical Association offered a 12-month grace period. During this grace period, you could submit claims with a diagnosis that was "close enough," or at least found within the applicable family of codes, and still receive reimbursement. As long as you used a valid code, Medicare review contractors wouldn't deny physician or other claims billed under the Part B physician fee schedule through either an automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code.

While the goal of ICD-10 was to boost specificity in claims, the grace period may have instead promulgated ambiguity. CMS's grace period ends in October. Many commercial carriers are already denying more ICD-10 claims. Now's the time to address bad documentation practices, before they become bad habit. If your physicians are frequently reporting unspecified codes, find out why. If you've let your docs know that they need to be more specific, but they're still providing ambiguous documentation, show them the financial impact — delayed, denied or inadequate reimbursement.

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