ICD-10 Grace Period Is Nearly Over
Come October, you can expect to see a resurgence in claim denials.
W
hen CMS finally rolled out ICD-10 last October after
repeated delays, the new code set wasn't nearly as cata-
strophic as some had forecast. Rather than a complete
meltdown of claims processing, denials were relatively few, usually
due to either invalid code selections or valid diagnoses previously
covered in ICD-9 that were wrongly considered to not meet medical
necessity requirements under ICD-10. Now that we're several months
into ICD-10, you may be breathing a sigh of relief, thinking you're over
the hump. Not so fast. We're starting to see a resurgence in denials.
This uptick is likely because CMS and other carriers are beginning to
apply more stringent edits when adjudicating claims.
Close enough no longer good enough
If you remember, when ICD-10 was first
implemented, CMS in collaboration
with the American Medical
Association offered a 12-month
grace period. During this grace
period, you could submit claims
with a diagnosis that was "close
enough," or at least found within the
applicable family of codes, and still
receive reimbursement. As long as you used
a valid code, Medicare review contractors
wouldn't deny physician or other claims billed
under the Part B physician fee schedule through
either an automated medical review or complex
medical record review based solely on the speci-
Coding & Billing
Cristina Bentin, CCS-P, COC, CMA
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