After the ICD-10 transition: Your questions answered

Q: Is the Centers for Medicare & Medicaid Services (CMS) allowing submission of less specific ICD-10 codes for the first year? If so, does that mean that claims will not be denied if they are submitted with an ICD-10 code that is not at the maximum level of specificity?

A: At the end of September 2015, CMS clarified that, if the level of specificity required by a Local Coverage Determination (LCD) or National Coverage Determination (NCD) isn’t met, the claim will be denied. This is because the ICD-10 codes in LCDs and NCDs have the same level of specificity as ICD-9 codes, so the automated claims processing edits are not being modified.

20 bizarre new ICD-10 codes

In addition, each ICD-10 code on a claim must be a valid ICD-10 code. If the submitted code is not recognized as a valid code, the claim will be rejected. You can resubmit the claim with a valid code, but make sure the physician or provider is choosing the more specific code.

CMS’ definition of a “valid” code is one that is coded to the highest level of specificity. ICD-10 is composed of codes with three to seven characters. Codes with three characters are included in ICD-10-CM as the heading (or parent code) of a category of codes. The category may be further subdivided by using fourth, fifth, sixth, or seventh characters, which include greater specificity. A three-character code should be used only if it is not further subdividedx.

For the first year (until October 1, 2016), if a valid code from the correct category (or family) is submitted, CMS will process and not audit the claim.

Next: What should I do if my claim is rejected?

Example:

C81 (Hodgkin lymphoma)

This code by itself is not a valid code. Valid codes within this category have 5 characters, such as:

• C81.00 Nodular lymphocyte predominant Hodgkin lymphoma, unspecified site

• C81.03 Nodular lymphocyte predominant Hodgkin lymphoma, intra-abdominal lymph nodes

• C81.10 Nodular sclerosis classical Hodgkin lymphoma, unspecified site

• C81.90 Hodgkin lymphoma, unspecified, unspecified site

Using any one of the valid codes for Hodgkin lymphoma (C81.00, C81.03, C81.10 or C81.90) would not cause a denial. Also, if the paid claim were to be selected later for audit by a Medicare review contractor, the claim would not be denied simply because the wrong code was included, as long as the code was in the same family, which in this case is C81.

Related: ICD-10: More frustration than chaos for physicians

Q: What should I do if my claim is rejected? Will I know whether it was rejected because it is not a valid code rather than denied due to a lack of specificity required for a National Coverage Determination (NCD) or Local Coverage Determination (LCD) or other claim edit?

A: Although CMS does not give the specific denial codes, it should be clear that the claim is being rejected because the ICD-10 code wasn’t valid verses lack of specificity required for an NCD or LCD. Just make sure you read the denial reason carefully.

Renee Dowling is a billing and coding consultant with VEI Consulting in Indianapolis, Indiana. Send your billing and coding questions to: medec@advanstar.com.