ICD-10: CMS and AMA Announce a One-Year Grace Period

No, the title doesn’t mean ICD-10 is going to be delayed yet another year, although that would be believable considering the many delays and opponents of the changeover. Last week, however, CMS and the American Medical Association (AMA) released a joint statement hoping to ease the ICD-10 transition by instating a one-year grace period after ICD-10 codes go into effect. The partnership between the two organizations pretty much squashes any hopes for another ICD-10 delay (or leap-frogging to ICD-11) and nearly seals the deal on an Oct 1, 2015, start date.

Meeting in the middle

The AMA hasn’t been shy over the years about its stance on the ICD-10 transition. It has been a huge force in delaying the code set not once, but twice. However, after seeing that this year will finally be the year of transition (and a failed last-ditch effort to pass a two-year grace period bill to protect claims from being denied), the AMA decided to meet in the middle.

AMA president, Steven J. Stack, MD, believes these changes will “allow physicians to continue providing high-quality patient care without risking their livelihood.” Stack also stated that “these provisions are a culmination of vigorous efforts to convince the agency of the need for a transition period to avoid financial disruptions during this time of tremendous change.”

The changes address the following:

• Claim denials. For the first 12 months, Medicare claims will not be denied solely because the ICD-10 code submitted wasn’t specific enough as long as the code is from the appropriate family of ICD-10 codes. In other words, payment will not be denied for unintentional errors made during the ICD-10 learning phase. Medicare Administrative Contractors and Recovery Audit Contractors will also be required to follow this policy.

• Quality-reporting penalties. Similar to the point above, CMS will not subject providers to penalties for the Physician Quality Reporting System (PQRS), the value-based payment modifier, or meaningful use based on the specificity of diagnosis codes as long as they use a code from the correct ICD-10 family of codes. Furthermore, penalties will also not be applied if CMS experiences difficulties calculating quality scores for these programs as a result of ICD-10 implementation.

• Payment disruptions. Perhaps one of the biggest announcements is if Medicare contractors are unable to process claims as a result of problems with ICD-10, CMS will authorize advance payments to providers.

• Navigating transition problems. A communication center will be setup by CMS to monitor and resolve ICD-10 issues as quickly as possible. The communication center will include an “ICD-10 ombudsman” whose sole duty is to triage provider issues, such as inadvertent coding errors or system glitches that may result in an audit, claim denials, and penalties under various Medicare reporting programs. CMS and AMA will also jointly educate providers through webinars, on-site training, and national provider calls.

The Code-FLEX Act

It took no time after the announcement was made before a “piggy-back” bill was introduced to the House. H.R. 3018, also known as the “Code-FLEX” act, requests that healthcare providers should be allowed to submit claims in both ICD-9 and ICD-10 for the first six months. This bill is sponsored both by Reps. Marsha Blackburn (R-Tenn.) and Tom E. Price (R-N.C.) and has garnered support from the Medical Group Management Association (MGMA).

“The Code-FLEX act would give physician practices much-needed flexibility and provides a window of time to address inevitable system issues,” said Robert Tennant of MGMA. “This would ensure that claims are processed and paid in a timely manner and that physicians would continue to be able to provide care to their patients.”

Tennant likens the dual coding to the policy CMS instated during the 5010 upgrade (where both 5010 and 4010 were permitted for 6 months).

While proponents of the bill believe dual coding would ensure claims are processed and paid in a timely manner, others believe it would be unworkable, costly, and confusing.

The Coalition for ICD-10 believes a dual-coding system is not a simple solution, but is “fraught with difficulties that have the potential to undermine the data infrastructure of the healthcare industry.” Also, it will “confuse claims processing and negatively impact the handling of important patient clinical information and may affect patient care.”

Whether intentional or inadvertent, the dual-coding proposal is comparable to mandating another delay in ICD-10 implementation.

Boost of confidence?

What do you think about the announcement? Does it remove the biggest barrier of the code set transition (denied claims) or is there more that should be done? Or perhaps you are part of the crowd that wants to rip off the Band-Aid and just start already. Join the conversation and share your thoughts in the comments.

Diana Strubler, Senior Product Analyst, Health IT Standards, joined Acumen in 2010 as an EHR trainer then quickly moved into the role of certification and health IT standards subject matter expert. She has successfully led Acumen through three certifications while also guiding our company and customers through the world of Meaningful Use, ICD-10 and PQRS.