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September 2016
CLINICAL PRACTICE MANAGEMENT
Medicare Will Soon Require More Coding Specificity on Claims
The "grace period” for ICD-10 coding is coming to an end. Starting Oct. 1, claims must be coded to the greatest specificity as supported by the documentation. 
 
Previously, the Centers for Medicare and Medicaid Services (CMS) had allowed for flexibility to make the transition to the ICD-10 code set easier for providers. CMS had said that claims would not be rejected by Medicare Administrative Contractors (MACs) as long the claim had a valid ICD-10 code from the correct “family of codes.” A “family of codes” is defined as those codes contained in a three digit set that are clinically related. For example, C81 designates Hodgkin’s lymphoma, but does not provide any more specificity as to the type of Hodgkin’s lymphoma. 
 
Beginning Oct. 1, 2016 claims with only three digit ICD-10 codes may be subject to denial and audit. Therefore in order to avoid payment delays, CMS recommends providers should code to accurately reflect the clinical documentation, and with as much specificity as possible. CMS also recommends providers should avoid using unspecified diagnosis codes when clinical documentation may support the use of a more detailed code. For example, ICD-10 code A40 indicates Streptococcal sepsis. However, if the clinical documentation supports the use of a more specified code, such as A40.3 – Sepsis due to Streptococcus pneumoniae, then the more specific code should be reported on the claim. 
 
For more information and provider resources, visit the ICD-10 CMS webpage: CMS ICD-10 Information.


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