ICD-10 ‘grace period’ over, says CMS

The year-long ICD-10 ‘grace period’, designed to allow practices time to adjust to new codes, has ended.

CMS had offered a practices time to get used to ICD-10 by not denying claims that had codes in the correct ICD-10 ‘family’. Whilst CMS's grace period only applied to Medicare and Medicaid reimbursements, it was echoed by some commercial payers too.

However, as of September 30th, practices are expected to be as specific as possible with the ICD-10 codes they use, or risk lost revenues due to post-grace period claims denials.

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CMS stated "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 the ICD-10 code as long as there is no evidence of fraud."

In addition to the need for greater code specificity presented by the end of the ICD-10 grace period, CMS has issued updates to ICD-10 and DSM-5 codes for mental and behavioral health

Mental and behavioral health clinicians have already encountered some challenges with unspecified codes, due to incongruities between the DSM-5 and the CMS code sets.

CMS has confirmed that clinicians can use unspecified codes when they are most appropriate, though clinicians must demonstrate medical necessity for the services provided.

CMS stated “While you should report specific diagnosis codes when they are supported by the available medical record documentation and clinical knowledge of the patient's health condition, in some instances signs/symptoms or unspecified codes are the best choice to accurately reflect the health care encounter. You should code each healthcare encounter to the level of certainty known for that encounter."