ICD-10 Flexibility Period Coming to an End

September 26, 2016
Rick Gawenda

On October 1, 2016, the Centers for Medicare and Medicaid Services (CMS) will end the 12 month flexibility period that they implemented on October 1, 2015. In July 2015, CMS announced “For 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.”

“Family of codes” is the same as the ICD-10 three-character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. For example, M25 – Other joint disorder, not elsewhere classified, is an ICD-10 three-character category. During the flexibility period, if the paid claim were to be selected later for audit by a Medicare review contractor, the Guidance makes it clear that the claim would not be denied simply because the wrong code was included, so long as the code was in the same family. As long as the selected code was within the M25 family, then the audit flexibility applies.

In August 2016, CMS issued new guidance stating it “will not extend ICD-10 flexibilities beyond October 1, 2016. There will be no additional flexibility guidance.” CMS further states “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.” To read the updated guidance from CMS regarding ICD-10 coding effective October 1, 2016,

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  1. Since APTA has come out with guidance for reporting the first code, does it have to be physicians treatment code or the therapy code that best describes what the therapist is treating?
    Thank you.

    1. This is from CMS: Bill the most relevant diagnosis. As always, when billing for therapy services, the diagnosis code that best relates to the reason for the treatment shall be on the claim, unless there is a compelling reason to report another diagnosis code. For example, when a patient with diabetes is being treated with therapy for gait training due to amputation, the preferred diagnosis is abnormality of gait (which characterizes the treatment). Where it is possible in accordance with State and local laws and the contractors’ local coverage determinations, avoid using vague or general diagnoses. When a claim includes several types of services, or where the physician/NPP must supply the diagnosis, it may not be possible to use the most relevant therapy diagnosis code in the primary position. In that case, the relevant diagnosis code should, if possible, be on the claim in another position.

      1. I agree with your comments above according to CMS, but the more recent guidance provided by ICDLogic in a webinar sponsored by the APTA, is stating to use the medical diagnosis as the first listed and then their primary symptom related to that fracture for the second listed dx.
        So, the example of unspecified fx of the left femur,,, would be the 1st listed and the 2nd listed (primary symptom) being difficulty in walking. would you agree with this from a compliance and payment perspective? Thank you..

        1. You have ICD-10 coding guidelines and then you have CMS and other insurance carriers guidelines and sometimes they do not agree. I do not believe a PT is treating the fracture. I believe they are treating the pain associated with the fracture, muscle weakness present due to surgery due to the fracture, stiffness of the joint due to the fracture and possible surgery, difficulty in walking if a L/E fracture, etc.