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AMA & CMS Agree to 1-Year ICD-10 Implementation Flexibilities

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Three months before the Oct. 1, 2015 deadline, the Centers for Medicare & Medicaid Services (CMS) and the AMA announced efforts to help physicians prepare for ICD-10. Responding to AMA concerns, CMS issued a guidance on 5 AMA-CMS agreed-upon flexibilities for a year-long implementation period of ICD-10, covering denials based on code specificity, audits based on code specificity, coding and quality reporting programs, establishment of ombudsman and authorization of advanced payments.

No Denial Based Solely on Specificity

For a 1-year period starting Oct. 1, 2015, Medicare claims will not be denied solely on the specificity of the ICD-10 diagnosis codes provided, as long as the physician submitted an ICD-10 code from an appropriate family of codes.

No Audit Based Solely on Specificity

In addition, from Oct. 1, 2015 to Sept. 30, 2016, Medicare claims will not be audited based on the specificity of the diagnosis codes as long as they are from the appropriate family of codes. This policy will be followed by Medicare Administrative Contractors and Recovery Audit Contractors.

No Penalty Based on Coding Changes in Quality Programs

To avoid potential problems with midyear coding changes in CMS’s quality programs (PQRS, VBM and MU) for the 2015 reporting year, physicians using the appropriate family of diagnosis codes will not be penalized if CMS experiences difficulties in accurately calculating quality scores (i.e., for PQRS, VBM or MU). CMS will continue to monitor implementation and adjust the duration if needed.

Ombudsman Established

CMS established an ICD-10 ombudsman to help receive and triage physician and provider problems. CMS closed its ICD-10 Coordination Center, which included the ICD-10 ombudsman, at the end of January 2016 due to limited reports of issues.

Advanced Payments Authorized

CMS will authorize advanced payments if Medicare contractors are unable to process claims within established time limits due to problems with ICD-10 implementation. CMS’s announcement shows that the agency is responding to physician concerns.

The AMA continues to monitor and apprise CMS of any implementation issues that have emerged in 2015 and persist in 2016. To do this, we encourage the state, county and specialty medical societies represented in the AMA House of Delegates to report to us any problems their members experience during the transition, to better inform our advocacy efforts on their behalf. We will urge the agency to make any needed adjustments to the grace period policy and time line based on new information that surfaces during the implementation process.

To learn more and stay apprised on developments, read the latest news in AMA Wire®.

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