How is CMS Resolving ICD-10 Issues?

The Centers for Medicare & Medicaid Services (CMS) recently announced that the transition to ICD-10 caused barely a blip on its radar. As it turns out, though, that optimism doesn’t outweigh the fact that there have indeed been issues on Medicare’s end—and they’ve caused more than a blip in providers’ workflows. Here’s what we know so far:

NCDs and LCDs

The “isolated” issues surround National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). This AACE document defines these terms as follows: “NCDs (National Coverage Determinations) and LCDs (Local Coverage Determinations) are decisions by Medicare and their administrative contractors that provide coverage information and determine whether services are reasonable and necessary on certain services offered by participating providers.” Translation: NCDs and LCDs outline allowable diagnosis codes for payment—which means that when there’s an issue affecting these policies, claims don’t get paid.


In the case of NCDs, claims have been inappropriately rejected or denied. CMS has indicated it is committed to resolving these issues quickly. Specifically, the organization is:

  • automatically reprocessing wrongly rejected or denied claims (in most cases), without requiring any action or additional fees from the affected providers;
  • providing further clarification on, and refinement of, NCDs;
  • creating a permanent system to resolve issues by January 4, 2016; and
  • making information available on Medicare Administrative Contractors (MAC) websites.


Some MACs failed to update certain LCD criteria, which resulted in additional errors. CMS is postponing processing these claims until the updates are complete. In the future, if any claims come in with these same errors, CMS will pause processing until the MACs make the required updates. If providers have any questions, they should contact the appropriate MAC.


Before October 1, CMS made it a point to announce its ICD-10 readiness. Even back in July, the testing results touted success: “the agency stated that its last test run resulted in an 87 percent claims acceptance rate of the 29,286 tests the agency received. The rejection rate for ICD-10 errors was 1.8 percent and the rejection rate for ICD-9 errors was 2.6 percent.” Furthermore, CMS repeatedly assured providers that they had enough resources and staff to effectively handle the transition. In essence, CMS appeared to be totally prepared to tackle the transition.

Or Not

Now, it appears that CMS wasn’t as prepared as we’d all hoped—and believed. Plus, as this Healthcare Payer News article points out, “it’s worth keeping in mind that the government agency has taken several temporary steps to smooth the transition to ICD-10 which may be masking problems that could manifest themselves down the road.” Ouch. But, CMS isn’t the only entity that could encounter problems. This Healthcare Finance article also gives a grim forecast for providers: “Providers that considered themselves unprepared for ICD-10 as October 1 approached shouldn’t assume their currently low claims rejection rates mean their self-assessment was overly pessimistic. If they felt they were unprepared, they probably were. And if they were unprepared for ICD-10 on October 1, they probably still are.”


As explained here, “CMS contractors have moved quickly to take action, such as temporarily suspending edits and/or claims, making fixes as quickly as possible, and reprocessing claims to minimize impact on providers.” That may be reassuring, but we’ve yet to see whether providers themselves were truly ready for the transition.