ICD-10: Is There Really a Grace Period?

With the implementation of ICD-10 beginning on October 1, 2015, I am often asked about this supposedly “grace period” that the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) agreed to back on July 6, 2015 and how it will help providers if they do not select the most appropriate ICD-10 code for the Medicare beneficiary. To clarify, CMS and the AMA are not calling this a “grace period”, rather, is calling it ICD-10 flexibilities.

CMS published a question and answer document concerning the CMS/AMA Joint Announcement and guidance regarding ICD-10 flexibilities and here is what the joint statement says in question #3: “While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, if a valid ICD-10 code from the right family is submitted, Medicare fee-for-service will process and not audit valid ICD-10 codes unless such codes fall into the circumstances described in more detail below.”

So the question you now have is what is meant by the right family and can you give me an example as it would pertain to outpatient therapy services? Of course I can. “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.

Lets say you have a patient referred to therapy and during the evaluation process, it is noted the patient has pain in their right shoulder that you will code as a sign and symptom as a reason for therapy. The category for pain would be