We’re not off the hook anymore: The ICD-10 grace period comes to a close October 1

September 7th, 2016

Remember when Y2K was approaching, and everyone was in a complete panic about what the unknown abyss of change was going to do with basically every computer system in the world? And then January 1, 2000 came along…and, nothing. Things just magically kept on operating as normal. Just like that, Y2K was old news.

In the healthcare coding world, the implementation to ICD-10 was pretty comparable. There was a big fuss about it for a whole year leading up to it. It’s all we heard about in the coding world. And then? It was October 1, 2015 and things just kept on going without any major hiccups. At the time of go-live, CMS implemented a grace period and said it would not deny claims as long as healthcare providers used codes in the correct “family” related to the treatment. “ICD-10 flexibilities were solely for the purpose of contractors performing medical review so that they would not deny claims solely for the specificity of theICD-10 code as long as there is no evidence of fraud,” CMS said. The grace period had only applied to claims submitted to Medicare and Medicaid, and while many commercial insurers offered similar flexibility, the majority did not.

As a recent HealthIT Analytics article points out, healthcare providers have been off the hook during this grace period when it came to the detail and specificity in documentation required of ICD-10. But now that the grace period is coming to an end, providers will need to focus on EHR data quality improvement efforts. No more sweeping things under the rug; no more being off the hook. Providers will now be held to using the correct degree of specificity in their coded claims.

After October 1, higher levels of data integrity and precision in clinical documentation could make the difference between a successful payment and an immediate denial. Here’s an example the article gives – the coding family for Hodgkin’s lymphoma, for example, is labeled as C81. By itself, C81 is not a valid ICD-10 code, since it does not contain five characters. But any of the following codes could be used to indicate Hodgkin’s lymphoma in a patient, even though their specific meanings are notably different:

  • C81.00 Nodular lymphocyte predominant Hodgkin lymphoma, unspecified site
  • C81.03 Nodular lymphocyte predominant Hodgkin lymphoma, intra-abdominal lymph nodes
  • C81.10 Nodular sclerosis classical Hodgkin lymphoma, unspecified site
  • C81.90 Hodgkin lymphoma, unspecified, unspecified site

During the past year, providers have not been penalized for using any one of those four codes interchangeably. But after October 1, physicians will have to be absolutely certain that their clinical documentation distinguishes between the four types of lymphoma.

Physicians be warned: there are no more excuses, according to CMS. As soon as the flexibility period ends, auditors will once again be able to use code specificity as a reason to deny ICD-10 claims.

The end of this transitional period could be a rocky one if coding professionals and providers neglect to prepare for it. While the grace period is coming to an end, CMS said providers will still be allowed to use unspecified codes in a few instances where usage of unspecified ICD-10-CM codes may be appropriate, but widespread use of numerous unspecified codes will be the exception, not the rule.

Are you ready for the end of the grace period? If you continue to submit unspecified ICD-10 codes after October 1, you may potentially experience an increase in claims rejections. And as rejections increase, so will payer requests for medical records and clinical documentation. Don’t let this catch you off guard! We have all the tools you need to make this a smooth transition.