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ICD-10 “FlexibilitiesCMS had granted healthcare providers, hospitals and medical coding companies a one-year grace period for ICD-10-coded medical claims. An ICD-10 coding flexibility policy was implemented last year specifically for the claims submitted to Medicare and Medicaid. As this code set is approaching its first year of implementation, CMS has announced the end of the given concession.

Before the implementation of ICD-10 on October 1, 2015, the Centers for Medicare & Medicaid Services (CMS) and the AMA announced efforts to help physicians prepare for ICD-10. CMS issued guidance on certain flexibilities agreed by both the agencies for a year-long implementation period of ICD-10. As per the guidance, Medicare claims will not be audited or denied based 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.

An ICD-10 ombudsman was also established to help “receive and triage physician and provider issues.” Due to limited reports of issues, the organization has closed its ICD-10 Coordination Center, which included the ICD-10 ombudsman. Advanced payments were also authorized if Medicare contractors are unable to process claims within established time limits due to problems with ICD-10 implementation.

It was also reported that an additional 5,500 codes will be added to the list by the end of this grace period. These new codes relate to devices, the addition of bifurcation as a qualifier, additional body parts, and codes related to congenital cardiac procedures and placement of intravascular neurostimulators.

According to CMS, “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.”

ICD-10 was implemented mainly because of the higher degree of detail that it allows to describe the services provided. Medical coding specialists should make sure to avoid unspecified ICD-10 codes whenever documentation supports a more detailed code. However, when sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code. It is also crucial to check the coding on each claim to make sure that it aligns with the clinical documentation.

While moving to an era of more strict usage of these code sets, physicians should be careful to choose a medical billing company that adheres to updated CMS guidelines.