Health Information Management

What does AMA and CMS ICD-10 agreement mean for hospitals?

APCs Insider, July 17, 2015

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By Steven Andrews
Providers got an unexpected surprise following the Fourth of July holiday when CMS and the American Medical Association (AMA) released a joint announcement declaring an apparent ceasefire in the battle over ICD-10.
The AMA and some members of Congress were still pushing for a delay just a few months ago, but after passage of the Sustainable Growth Rate bill, it became clear that ICD-10 wasn’t going to get delayed again.
ICD-10 opponents began to change tactics, instead focusing on a two-year grace period during which payers would excuse all ICD-10 coding errors. The AMA began to walk that request back to clarify the association would be okay with an exemption for unspecified codes.
The agreement between the AMA and CMS means that:
  • For one year after implementation, MACs will not deny Part B physician fee schedule claims based solely on the specificity of the ICD-10 code as long as the code is from the correct family
  • For program year 2015, penalties related to the Physician Quality Reporting System, Value-Based Modifier, or Meaningful Use programs will not be applied based on ICD-10 code specificity if the code is from the correct family. 
  • If MACs are unable to process claims in a timely fashion due to system malfunctions or implementation problems, partial advance payments, which have to be repaid, will be made
CMS is also establishing a communications center to quickly resolve ICD-10-related issues and appointing an ICD-10 ombudsman to triage provider concerns.
These might seem like big concessions from CMS, but in reality, it’s a small price to pay to get the AMA to stop its opposition. As I wrote  before this agreement, providers are unlikely to get penalized for unspecified codes in the first year of implementation regardless—the ICD-10-CM Official Guidelines for Coding and Reporting (I.B.18) specifically allow unspecified codes. And advance payments due to CMS errors should be a given. The agency says it’s ready, and providers shouldn’t suffer if it’s not.
Two big questions remain, which CMS has not responded to as of press time. The first is what a “family” of codes means. Does this mean a category? A subcategory? Providers need clarification on this point before implementation.
The second question you’re probably asking is, what does this mean for me? CMS specifies physician fee schedule payments in its guidance, but makes no mention of hospitals.
On the one hand, hospitals are far more likely to be prepared for ICD-10 than physician practices. On the other, hospitals bore the brunt of the cost of delays the AMA fought for. It’s hard to believe hospitals wouldn’t be given some sort of reprieve along with physicians. However the normally vocal American Hospital Association has made no comment on the agreement.
Hopefully, with its new commitment to communication and the addition of an ombudsman, CMS will soon be able to answer these pressing questions for providers.


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