Get the Truth on CMS’s ‘No Denials Based on ICD-10 Code Specificity’ Promise

ICD-10 transition, ICD-10 training, ICD-10 elearning, ICD-10 implementation

CMS, AMA shake hands on ICD-10 transition plans

With the ICD-10 transition deadline of October 1 looming, CMS and the AMA announced a compromise that will allow providers to get more help with the transition, as well as some relief from potential claim denials.

According to CMS guidance issued July 6, for the first year that ICD-10 is in place, Medicare Administrative Contractors (MACs) will not deny Part B claims solely on the specificity of the ICD-10 diagnosis code. However, CMS said it will require a valid ICD-10 code on all claims for dates of service occurring on or after October 1.

Steven A. Stack, MD, president of the AMA, said that the new guidance means “Medicare will not deny payment for these unintentional errors as practices become accustomed to ICD-10 coding.” He added, “This transition period will give physicians and their practice teams time to get up to speed on the more complicated code set.”

Specifically, the CMS-AMA announcement affects:

Claims denials

CMS said that for the first year after ICD-10 implementation, Medicare review contractors won’t deny eligible professional Part B claims based solely on the specificity of the ICD-10 diagnosis code, though contractors could choose a claim for review for other reasons. You still must report a “valid code from the right family,” though. CMS said that Medicare Administrative Contractors, the Recovery Audit Contractors, Zone Program Integrity Contractors, and Supplemental Medical Review Contractors will follow this policy.

Quality reporting and other penalties

CMS said also that 2015 quality reporting programs would not penalize physicians for insufficient specificity related to ICD-10 coding. “For all quality reporting completed for program year 2015, Medicare clinical quality data review contractors will not subject physicians or other Eligible Professionals (EPs) to the Physician Quality Reporting System (PQRS), Value Based Modifier (VBM), or Meaningful Use 2 (MU) penalty during primary source verification or auditing related to the additional specificity of the ICD-10 diagnosis code, as long as the physician/EP used a code from the correct family of codes,” the CMS guidance report stated.

CMS added that EPs won’t face a penalty if CMS has trouble calculating quality scores for PQRS, VBM, or MU2 due to the ICD-10 transition period.

Help for payment disruptions

According to AMA President Stack, if Medicare contractors are unable to process claims because of problems with ICD-10, CMS will authorize advance payments to physicians. CMS said that such problems could include contractor system malfunctions or implementation issues, and that an advance payment would be a conditional partial payment that would require repayment. CMS said that it did not have authority to make advance payments in cases where physicians could not submit a valid claim for services rendered.

New CMS Ombudsman for ICD-10 implementation

CMS said it will set up a “communication and collaboration center for monitoring the implementation of ICD-10,” to quickly identify and resolve issues related to the transition. This center will include an ICD-10 Ombudsman to help receive and triage provider issues, working closely with representatives in CMS regional offices.

CMS-AMA Agreement Follows Flurry of ICD-10 Legislation

So far this year, legislators have introduced a number of ICD-10 transition bills in Congress. The first, H.R. 2126, Texas Republican Rep. Ted Poe’s Cutting Costly Codes Act, would have completely stopped ICD-10 from replacing ICD-9. AMA officials publicly supported H.R. 2126. Another bill was Tennessee Republican Rep. Diane Black’s H.R. 2247, the Increasing Clarity for Doctors by Transitioning Effectively Now (ICD-TEN) Act, which would have created an open-ended transition period. Also, Alabama Republican Rep. Gary Palmer’s H.R. 2652, the Protecting Patients and Physicians Against Coding Act of 2015, would have required a two-year grace period for claims denial due to ICD-10 transition-related mistakes.

Don’t Start Sloppy Habits — Code ICD-10 Right From the Start

The CMS announcement makes it clear that “diagnosis coding to the correct level of specificity is the goal for all claims.” You also should not assume all payers will follow suit with ICD-10 “amnesty.” Complete your ICD-10 training checklist for clinical documentation improvement and coding education with SuperCoder’s code sets, eLearning, and automated workflow solutions.

SuperCoder data sets can help you update your coding database or charge master for ICD-10-CM implementation with a developer-ready code set format that includes the same hierarchical arrangement that CMS uses.

Most healthcare professionals never trained on every single ICD-9 code – they just learned the ones they worked with each day. SuperCoder’s ICD-10 eLearning training homes in on the diagnoses you need to know for your specialty in about an hour, while protecting your cash flow with tips and advice on clinical documentation improvements to keep reimbursements rolling in with fewer denials.

And don’t miss BoneCoder10, the automated ICD-10 coding tool, a streamlined workflow solution that covers all specialties! Assign the correct ICD-10 code in less than 30 seconds by clicking anatomical images and drill-down menu options complete with coding tips and guidelines.


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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