ICD-10 replaced ICD-9 coding system last year, and October 1, 2016 marked one year of the substitution. Reports say that the latest ICD-10 coding model increased the amount of data that is captured by the diagnostic codes. It also enhanced the specificity regarding disease severity and offered more data on specific anatomy the condition or disease is affecting.
Rather than diagnosing a broken bone, ICD-10 offers healthcare providers a chance to document specific details such as which bone is broken, on which part of the body, and what is the severity of fracture. This ability of granular documentation led to the increase from about 14,000 ICD-9 codes to 70,000 codes in ICD-10.
The provider community, HBMA membership, and the other stakeholders were much anxious about this big increase in codes and questioned on the possibility of healthcare revenue cycle system seamlessly transitioning to ICD-10 without disruptions or issues in payments. However, the deadline to migrate came and went with only a few minor disruptions.
Claims adjudication rules required that a claim be coded to greatest degree of specificity that is available. As the information embedded in ICD-9 code was not much specific when compared to what is in ICD-10 code, the chances of a claim being rejected due to lack of specificity was less under ICD-9. Yet again, with ICD-10 the possibility of claims being rejected due to lack of specificity increased many folds.
Under ICD-10, it was not enough to choose a code, which indicates that the patient had a broken bone. The health provider should also give details on cause and laterality of the issue. A common concern was about the specificity of a claim to be not rejected.
There was pushback from AMA, HBMA, and others, due to which CMS announced a grace period of one year to ensure that the medical reviews by contractors did not deny a claim due to the lack of specificity. This grace period of one year expired on October 1, 2016 and CMS announced publicly in an updated FAQ page that this grace period will not be extended further.
As per the announcement from CMS, the providers should code to the highest level of specificity, and the grace period offered was limited to contractors who perform medical reviews. The announcement also says that the grace period did not apply to insurers who set their own policies on coding flexibility.
CMS has also provided a couple of resources to assist stakeholders use the ICD-10 coding system correctly, which includes an updated catalog of ICD-10 codes as well as educational materials on varied topics, such as unspecified codes in ICD-10 and choosing the appropriate specificity for a claim.