Details of CMS’s ICD-10 “Family” Business

ICD-10 Family, icd-10 codes, cms, ama, lcd, ncd, icd-10 family

Curious about CMS’s guidelines regarding code families? The CMS-AMA compromise this summer included the agreement that for one year, CMS will not deny Medicare claims based on ICD-10 specificity as long as you report valid ICD-10 codes from the correct “family.” The term “family of codes” refers to the same thing as an ICD-10 three-character category, CMS said, adding, “Codes within a category are clinically related and provide differences in capturing specific information on the type of condition.”

Meet the Cataract Family

For example, if an ophthalmology practice reports an anterior subcapsular polar age-related cataract of the right eye, the correct code is H25.031. But, if you incorrectly report H25.9 (Unspecified age-related cataract), the Medicare Administrative Contractor (MAC) should not deny your claim — at least, that is, within the one-year grace period after Oct. 1, 2015. Note that you must report a valid ICD-10 code, however, which means that you can’t just report H25- (Age-related cataract).

Don’t Expect a Moratorium on All Claims Denials From Medicare

This doesn’t mean Medicare won’t deny claims — the relaxation on coding specificity is limited to the aforementioned “code family” provision. CMS denies claims now under ICD-9, and you should expect to see similar denials when ICD-10 becomes effective. CMS denies claims for reasons varying from billing Medicare as primary when it should be secondary to reporting the wrong CPT® code. However, CMS promises that its MACs’ remittance advice will include denial codes that explain the reason for the denial.

Mind Your NCDs and LCDs to Avoid Denials

One more wrinkle in the no-denials announcement from CMS: National coverage determinations (NCDs) and local coverage decisions (LCDs) apply. This means that if an NCD or LCD specifies certain requirements for a service to be eligible for coverage, claims must meet those requirements. If your claim doesn’t meet the NCD and LCD requirements, expect a denial.

LCDs document decisions made by MACs regarding coverage for a specific service or item. When the MAC, which is in charge of Medicare services for a local area, rules on coverage for a service or item, that ruling is called an LCD, or local coverage decision or determination. When CMS decides on coverage, it creates a national coverage decision or determination (NCD).

Locals Rule – At Least as Far as Coverage Determination

A given service or item can have LCDs and NCDs that differ, so it’s important to check both before billing. MACs handle most Medicare coverage on a local level, determining coverage with LCDs. You can find LCDs and NCDs at the Medicare Coverage Database or as part of your Fast Coder or Physician Coder subscription.

Note that when an LCD and an NCD exist for the same service, the local coverage decision rules when the local MAC’s policy is more restrictive than the national one. While LCDs must be in line with NCDs, LCDs can further define the national coverage determinations for local providers.

How to Reach Dr. Rogers, the CMS Ombudsman

The CMS-AMA announcement also promised that CMS would name an ICD-10 ombudsman to help providers troubleshoot Medicare problems after the ICD-10 implementation. CMS named the new ombudsman, William Rogers, MD, a practicing ER physician at Georgetown University Hospital, in late August. Though his office may not be fully operational before October 1, you can contact Dr. Rogers now at

What About Private Payers?

CMS’s agreement with AMA to accept less specific ICD-10-CM codes applies only to Medicare fee-for-service claims billed under the Part B physician fee schedule, and Medicaid is specifically excluded by CMS in its announcement.

Private payers are not bound to CMS’s agreement. As CMS says, “Each commercial payer will have to determine whether it will offer similar audit flexibilities.” In August, the American Gastroenterological Association (AGA) reported that few third-party payers planned to follow CMS’s grace period. The AGA posted links to announcements from several payers, but your safest bet is to contact your payers individually to find out how they will handle this “family business.”

How is the CMS-AMA Compromise Affecting Your Practice?

Many experts think this compromise sealed the fate for ICD-10, making it a sure bet to be implemented this year (though as I write this, Congress still has 20 days left to throw a wrench in the works.) How do you think the “family of codes” concept will affect your practice’s bottom line? Let us know in the comments box below. We love to hear from you!

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Susan taught health information and healthcare documentation at the community college level for more than 20 years. She has a special love for medical language and terminology. She is passionate about ensuring accurate patient healthcare documentation through education. She has a master's degree in healthcare administration, is a certified healthcare documentation specialist, and serves as immediate past president for the Association for Healthcare Documentation Integrity (AHDI).

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