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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