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The end of ICD-10 flexibilities is coming, are you ready?


Providers who are still adjusting to the ICD-10 coding transition from five characters to seven have a variety of amenities and advice available to them in the last leg of the grace period.

Providers who are still adjusting to the ICD-10 coding transition from five characters to seven have a variety of amenities and advice available to them in the last leg of the grace period.

The flexibilities that the Centers for Medicare and Medicaid Services (CMS) allowed for following the launch of ICD-10 October 1, 2015-such as a leniency in the specificity of the codes submitted by providers-will be ending October 1, 2016.


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As a result of the grace period's conclusion, Jackie Stack, BSHA, CPC, an education specialist at the American Academy of Professional Coders, says providers should prepare for more audits and denials of claims, especially if codes they're submitting are unspecified.

“If you have the providers who really base most of their diagnoses on reporting on these unspecified codes, it's going to be a huge financial hit to that provider if Medicare starts to not pay based off of those codes,” Stack says.

The CMS released a Q&A list in August, providing guidance to the wrap-up for the flexibilities. One CMS example indicates the difference between “valid codes” and the “correct code.” If a patient receives the diagnosis of G43.711 (Chronic migraine without aura, intractable, with status migrainosus), then G43.701 (Chronic migraine without aura) or G43.719 (Chronic migraine without aura, intractable without status migrainosus), have not been “cause for an audit” during the grace period because those codes fall within the same family of codes, as noted by the first three characters.

Providers need to “make sure the clinical documentation is a complete and accurate reflection of the patient’s clinical picture and that the codes are as specific as possible based on that documentation,” Sue Bowman, RHIA, FAHIMA, senior director, coding policy and compliance at the American Health Information Management Association, said in an email to Medical Economics.


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“This will help to reduce claims denials, support medical necessity, obtain proper reimbursement, and accurately reflect clinical complexity and severity of illness.”

Many providers are already familiar with using specific codes because many major insurers did not offer a grace period, she notes.

Next: Avoiding an undue financial burden


However, for Pamela J. Miller, OD, in Highland, California, who participated in the ICD-10 diaries for Medical Economics, getting up to speed with the new code set has “absolutely” been burdensome, and she's taken to coding for herself following the launch of ICD-10.

“If the doctor isn't able to code it, it's very difficult to rely on ... staff to try and make the code where it's specific and it's exact,” Miller says, mentioning that her staff is very good and if she doesn't write the code down, they'll follow up with her for clarification.


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To avoid an undue financial burden, and to find the right method for implementing ICD-10 in your practice, here are five tips to consider:

1. Be specific. “The government has basically given everybody about a year to get their ducks in order, but we're now at the point where you really should not be using the unspecified code,” Miller says.

While that might seem straightforward enough, there are exceptions when unspecified codes are acceptable. For example, if a patient has been diagnosed with pneumonia, but the specific type has not yet been determined, “it is acceptable to report the appropriate unspecified code,” according to CMS.

One element added with the new code set is laterality-the right or left, which must be reflected when selecting a code, Stack adds.

2. Be accurate. Make sure specificity is reflected in the documentation, Stack says, mentioning the saying in coding: “not documented, not done,” meaning if physicians don't reflect every detail in their documentation, that won't be included when the codes are entered because the documentation and the codes have to match.


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When the deadline ends, providers will be required to code to accurately reflect the clinical documentation in as much specificity as possible, as per the required coding guidelines, according to CMS.

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3. Communicate. Communication between the provider and the billing staff is also imperative, Stack explains, especially if claims are being denied, they need to be corrected quickly, and the provider might not be aware.

“They're depending on their staff to take care of that for them,” she says. ”Their staff needs to make sure, if they want to see change from that provider, they've got to let them know what needs to be changed, what is lacking in their documentation, so that they can make that change and make it better so they stop getting that denial and they stop using those codes that they shouldn't be.”


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4. Practice. With ICD-10 underway, the CMS Road to 10 website also indicates that providers should ensure that their documentation matches the codeset. In order to practice using ICD-10, the site offers resources for providers in various specialties, which includes downloadable guides, common codes and clinical scenarios, to name a few.

5. Be vigilant.  Following a five-year code freeze, a number of new procedure and diagnostic codes will be added into the mix. Starting October 1, the changes include 1,943 new codes, 422 revised codes and 305 deleted codes.


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“That's something that [providers] want to make sure that somebody in their office is paying attention to, because they want to make sure that those changes get added into system, that they are aware of them, because that's going to make a big difference,” Stack says.


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