Health Information Management

AMA clarifies its intent with ICD-10 grace period

APCs Insider, June 26, 2015

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By Steven Andrews
The bill from Congress calling for a two-year grace period during which providers are not penalized for "errors, mistakes, and other malfunctions" related to the ICD-10 transition is remarkable for its broadness.
Coding "errors" can occur in a number of ways, from reporting the wrong laterality to entirely different diagnoses, but the bill, and the similar resolution passed by the AMA, don't attempt to define what they consider an error.
Steven Stack, MD, the new president of the AMA, attempted to clarify the resolution in a recent interview with HealthLeaders Media. "We are asserting that if we properly diagnose somebody with hypertension and say it's a new diagnosis, then the payers should not be able to deny a claim because we're unable to say that it was hypertension new diagnosis, secondary to renal disease, secondary to diabetes, secondary to poverty or some other things,” Stack said.
"When we get to these layers of specificity that ICD-10 permits, it is very important that payers not deny payment for lack of some falsely perceived level of specificity that the physician may not be able to provide," Stack continued.
Stack is right. Payers, including CMS, shouldn't be able to deny a claim immediately after implementation for reporting an unspecified code for those types of diagnoses. Fortunately for providers, the ICD-10 guidelines specifically address this topic:
While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter.
CMS even published a fact sheet dispelling common ICD-10 myths and said:
While documentation supporting accurate and specific codes will result in higher-quality data, nonspecific codes are still available for use when documentation doesn’t support a higher level of specificity. As demonstrated by the American Hospital Association/American Health Information Management Association field testing study, much of the detail contained in ICD-10-CM is already in medical record documentation, but is not currently needed for ICD-9-CM coding.
The AMA has stated that ICD-10 will hinder providers’ ability to care for patients, but if physicians properly document the diagnoses important to each patient's care, the appropriate codes won't be that much more difficult to assign than in ICD-9-CM.
Nearly half of the additional codes are related to laterality, which providers should already be documenting. If the AMA thought this information was too burdensome for providers to document or useless for patient care and data, why would it include modifiers for laterality in its CPT® codes?
The greatest impediment to provider ICD-10 preparedness isn't the number of codes, it's the fear of wasting time due to another delay. A grace period with a blanket, ill-defined exemption for errors and mistakes is only going to convince providers they don't need to prepare for ICD-10.
If specificity is truly the problem for the AMA, why is it supporting such a radical resolution? A bill already exists in Congress that would allow an 18-month safe harbor during which providers wouldn't be denied payment for unspecified codes. The bill also calls for expanded end-to-end testing to allow providers to ensure their vendors and clearinghouses are properly prepared. 
The AMA's mischaracterization of ICD-10 isn't new, but its latest resolution goes several steps too far when a far more realistic bill was already on the table. By throwing its support behind new legislation, the organization reduces the chance any single bill has of gaining enough support to pass.


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