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Flexible No More—No ICD-10 Grace Period Past October 1

September 18, 2016:

Come October 1, the Medicare program expects providers to code accurately to the highest level of specificity under ICD-10-CM and –PCS. The so-called “grace period” of the last year is ending once and for all at the end of September. During this period, the Centers for Medicare and Medicaid Services (CMS) instructed payers to accept claims with valid codes that were at least in the right category. Payers will reject such claims in fiscal 2017.

CMS made this clear with an announcement on August 18. In the message, the agency mentioned that it had updated the “Clarifying Questions and Answers Related to the July 6, 2015, CMS/AMA Joint Announcement and Guidance Regarding ICD-10-Flexibilities” it posted on its website last summer (https://www.cms.gov/Medicare/Coding/ICD10/Clarifying-Questions-and-Answers-Related-to-the-July-6-2015-CMS-AMA-Joint-Announcement.pdf).

During the grace period of the last 12 months, Medicare payers accepted claims reporting valid codes in the correct category but not fully reflecting information in the documentation. For example, code G43.701 (Chronic migraine without aura) would have been accepted even though the documentation noted that the migraine lasted for longer than 72 hours and the most specific code would have been G43.711 (Chronic migraine without aura, intractable, with status migrainosus). Beginning October 1, such a claim will be rejected and have to be recoded and resubmitted for payment.

Note that CMS says that there is still a place for unspecified codes. For instance, if a physician has diagnosed pneumonia but has not yet determined the specific type, an unspecified code is appropriate.

Of course, specific coding relies on thorough documentation, and thorough documentation rests on providers knowing which details must be noted to support accurate coding. For this reason, ongoing education about documentation is a key part of the coding process.


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