Here's What You Need to Know About The AMA and CMS ICD-10 Announcement

“Extra! Extra! Read all about it!” When it comes to the Centers for Medicare & Medicaid Services (CMS), there’s no shortage of “extra” announcements in the news these days. And even though it’s not in print, ICD-10 news is especially important right now, as implementation is slated to take effect in just a few short months. If you’ve been following our blog, you’ve seen us cover everything you need to do before October 1 to prepare your clinic, but mistakes happen. That’s why CMS—with a push from the American Medical Association (AMA)—made a move that could help soften the blow of the transition. So, even if your preparedness doesn’t quite fit the bill (literally), you still have a chance of receiving payment come October 1. Here are the details of the recent announcement:

Flexible Review

CMS and the AMA want physicians and other practitioners (therapists included) to make a successful transition to ICD-10. So, they recently announced a 12-month period during which, according to CMS, “Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.” So, what does that mean?

Are providers off the hook for coding mistakes on Medicare claims?

The short answer is “no,” because:

However, if your claim doesn’t contain any errors other than those related to code specificity—and you’ve used a valid code from the correct family of codes—Medicare won’t deny your claim within that 12-month period.

How does this decision affect Medicare quality reporting?

CMS won’t apply accuracy penalties for programs like Physician Quality Reporting System (PQRS) as long as the eligible provider “submitted the requisite number/type of measures and appropriate domains on the specified number/percentage of patients, and the EP’s only error(s) is/are related to the specificity of the ICD-10 diagnosis code (as long as the physician/EP used a code from the correct family of codes),” says CMS.

ICD-10 Ombudsman

The ICD-10 Ombud—what? According to my handy-dandy online dictionary, an ombudsman is “a person (such as a government official or an employee) who investigates complaints and tries to deal with problems fairly.” And as part of this announcement, CMS described its plans to designate an ICD-10 ombudsman to investigate and help providers with their ICD-10 troubles during the transition. CMS hasn’t released many details about this resource other than the fact that the ombudsman will work closely with regional Medicare offices to better assist providers. As October 1 approaches, CMS will release more details on how you can contact the ombudsman for ICD-10 assistance.

Advanced Payment

What happens when there are system, administrative, or ICD-10 implementation problems with Medicare contractors? A conditional partial payment might be available. However, providers must repay any advanced payment, and they’re only eligible to receive such payments if they meet certain conditions.

What are the conditions?

CMS describes them in 42 CFR Section 421.214. Essentially, to receive advanced payment, Medicare suppliers can apply through their applicable Medicare Administrative Contractor (MAC).


Ultimately, CMS will review its flexible, 12-month timeline and adjust it based on the success of ICD-10 adoption. And don’t forget: Just because providers have some wiggle room when it comes to coding for complexity, it doesn’t mean they’re totally off the hook. The ultimate goal is to submit the most complete and accurate code—the first time, every time.