The Centers for Medicare and Medicaid Services on Oct. 1, 2016 will cease the year-long grace period wherein it accepted ICD-10 claims as long as they were submitted in the right family of codes. 

Ahead of the switch, CMS has now revised its Q&A "Questions and Answers Related to the July 6, 2015, CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities."

Here are the key revision hospitals and coders need to understand: 

Do the ICD-10 Medicare fee-for-service audit and quality program flexibilities extend to Medicare fee-for-service prior authorization requests?

No, the Medicare fee-for service audit and quality program flexibilities only pertain to post payment reviews. ICD-10 codes with the correct level of specificity will be required for prepayment reviews and prior authorization requests.

Do the Medicare fee-for-service audit and quality program flexibilities apply to Medicare Advantage?

No, the Guidance applies only to Medicare fee-for-service claims from physicians or other practitioners billed under the Medicare Fee-for-Service Part B physician fee schedule. Medicare Advantage risk adjustment payment and audit criteria remain unchanged.

Does the Guidance change coding guidelines?

No, coding guidelines are unchanged.

Will the Medicare review contractors be auditing the Medicare Advantage services according to this Guidance?

The Medicare review contractors only review Medicare fee-for-service claims. This Guidance does not apply to the Medicare Advantage plans.

Currently the guidance document only applies to services paid under the Medicare Fee-forservice
Part B physician fee schedule.

Will the Guidance be expanded to other provider/claim types? 

No, the Medicare fee-for-service audit and quality program flexibilities have not been expanded to other claim types. They only apply to physicians and other practitioners who bill under the Medicare Fee-for-Service Part B physician fee schedule.

The reason we focused on claims billed under the Part B physician fee schedule is because many physicians are in small practices that need additional flexibility to gain experience with the ICD- 10 coding set. Claims billed under the Part B physician fee schedule are paid using CPT codes and not ICD-10 codes. Other services, such as institutional services, are paid based on the ICD- 10 codes.

The ICD-10 Ombudsman will listen to issues raised by all suppliers and providers and will evaluate any specific issues that are raised during implementation. CMS’s ICD-10Coordination Center will be actively monitoring for any problems that may develop after October 1. This center will quickly identify and initiate resolution of issues that arise as a result of the transition to ICD-10.

Will physicians be allowed to submit a single advance payment request for multiple claims for services provided over a period of time?

CMS and its Medicare Administrative Contractors have conducted extensive testing forICD-10 and are ready for the transition on October 1, 2015. If the Part B Medicare Administrative Contractors (MACs) are unable to process claims within established time limits because of administrative problems, such as contractor system malfunction or implementation problems, an advance payment may be available.

Physicians would be allowed to submit a single advance payment request for multiple claims for an eligible period of time. Note an advance payment is a conditional partial payment, which requires repayment, and may be issued when the conditions described in CMS regulations at 42 CFR Section 421.214 are met. To apply for an advance payment, the physician is required to submit the request to their appropriate Medicare Administrative Contractor. Should there be Medicare systems issues that interfere with claims processing, CMS and the MACs will post information on how to access advance payments.

CMS does not have the authority to make advance payments in the case where a physician is unable to submit a valid claim for services rendered.

What are the “established time limits” to process claims?

Section 1842(c)(2) of the Social Security Act requires Medicare contractors to make payment on not
less than 95% of “clean claims” within 30 calendar days.

If there are Medicare systems issues that interfere with claims processing, CMS and the MACs will post information on how to access advance payments.

Will institutional providers (Part A) be able to submit requests for accelerated payments from Medicare?

CMS regulations at 42 CFR Section 413.64(g) allows accelerated payments for Part A providers not receiving periodic interim payments. This authority can be applied in the event of a contractor(s) delay in making payments or in “exceptional situations” where a provider has experienced a temporary delay in preparing and submitting bills beyond its normal billing cycle. Note an accelerated payment is a conditional partial payment, which requires repayment, and may be issued when the conditions described in CMS regulations at 42 CFR Section 413.64(g) are met and subject to contractor and CMS approval.

Will anything change during the one-year period of Medicare fee-for-service audit and quality program flexibilities with respect to Medicare crossover claims and the crossover process?

No, Medicare’s processes regarding what elements are crossed over to supplemental payers (including commercial payers and State Medicaid Agencies) will be unchanged as a result of the flexibilities.

How does the CMS 24-month look-back period for Medicare fee-for-service audits intersect with the 12-month period of audit flexibility? Will the auditors review and deny claims from theOctober 2015-October 2016 period for ICD-10 code specificity after October 2016?

Contractors conducting medical review (Medicare Administrative Contractors/Recovery Auditors/Supplemental Medical Review Contractor) will not deny claims solely for the specificity of the ICD-10 code as long as there is no evidence of potential fraud. This is consistent with current medical review policies and is not applicable to prepayment denials because of a National Coverage Determination or a Local Coverage Determination. 

Helpful advice for planning to purchase a population health platform:

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