ICD-10 ‘Flexibilities’ to End October 1

The Centers for Medicare and Medicaid Services (CMS) now expects that practices are “coding to the highest level of specificity” available under ICD-10, which adopted nearly one year ago. If your practice is not, CMS will no longer grant any ‘flexibility’ come Oct. 1, 2016.

Thanks to lobbying efforts by the American Medical Association and other groups before the new ICD-10 codes were implemented last year, CMS agreed to be flexible for one year giving practices some leeway and not denying 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 one year period of flexibility ends this October 1, and CMS has updated its FAQs to answer any concerns about whether your coding will be adequate. Review the full list of questions here.

Several of the key questions include:

  • Question 25: (new as of 8/18/2016) Is Medicare going to phase in the requirement to code to the highest level of specificity?

Answer: No, providers should already be coding to the highest level of specificity. ICD-10 flexibilities were solely for the purpose of contractors performing medical review so that they would not deny claims solely for the specificity of the ICD-10 code as long as there is no evidence of fraud. These ICD-10 medical review flexibilities will end on October 1, 2016. As of October 1, 2016, providers will be required to code to accurately reflect the clinical documentation in as much specificity as possible, as per the required coding guidelines. Many major insurers did not choose to offer coding flexibility, so many providers are already using specific codes.

  • Question 26: (new 08/18/2016) How do I get ready for the end of flexibilities?

Answer: Avoid unspecified ICD-10 codes whenever documentation supports a more detailed code. Check the coding on each claim to make sure that it aligns with the clinical documentation.

The CMS also has a state-by-state list (PDF) of ICD-10 resources and contact information, including phone numbers of Medicare administrative contractors and state Medicaid offices.

 
 

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1 Comment

  • Jose A Bardelas MD

    Will this lack of flexibility apply to all unspecified codes ? or just some ? Ex acute sinusitis unsp -J01.90