Comments on H.R. 2247
The Coalition for ICD-10 is strongly united in our support for the October 1, 2015 adoption of ICD-10. While we oppose any delays to this adoption date, we have been working with those who have expressed concerns to try to help them prepare for this transition. We remain committed to this outreach effort and encourage the Medicare program to have contingency plans in place for those who, despite best efforts, are still in need of transitional help on October 1, 2015.
HR 2247 seeks to smooth the transition to ICD-10 for physicians and includes provisions relating to the following:
CMS is already conducting extensive end-to-end testing, which is available to all health care providers and suppliers. They conducted a very successful end-to-end testing week in January, just completed another one in April, and a third one is planned in July. Indeed, CMS was able to accommodate all those who volunteered to test in January.
The April results have not been released yet, but the January results were very positive. Overall, participants in the January testing were able to successfully submit ICD-10 claims and have them processed through the CMS billing systems. Only 3% of rejected claims were due to ICD-10 coding errors. And in fact, this percentage is the same percentage CMS has previously stated are rejected each year following implementation of annual ICD-9 coding changes – demonstrating that the claims rejection rates are not likely to be significantly greater as a result of the ICD-10 transition. Most of the rejected claims during the ICD-10 end-to-end testing were due to reasons completely unrelated to ICD-10. These reasons included incorrect National Provider Identifier (NPI), Health Insurance Claim Number, Submitter ID, dates of service outside the range valid for testing, invalid HCPCS codes, invalid place of service – all reasons that a claim would be rejected today, regardless of the ICD coding system in use.
HR 2247 requires HHS to certify to Congress that the Medicare fee-for-service claims processing system is fully functioning. We believe CMS has already demonstrated the Medicare fee-for-service claims processing system is ready based on the results from the January end-to-end testing results.
Subcode Specificity and Accuracy
The underlying premise of HR 2247 is that “sub-coding specificity and accuracy” present a burden for providers. There are already appropriate mechanisms built into ICD-10-CM for reporting less specific codes when necessary and appropriate. There are “unspecified” codes in both ICD-9 and ICD-10, and unspecified ICD-9 codes are currently already allowed in Medicare fee-for-service payment systems. There is no indication that allowance of unspecified codes will change under ICD-10. There are also “default” codes when there is no “unspecified” option. For example, instructional notes in ICD-10 indicate that if a fracture is not documented as open or closed, it should be coded as closed. A common example of additional subcode specificity in ICD-10 is the requirement that the side of the body be specified as a subcode (right-left-unknown). However, the right/left distinction is already included as a CPT subcode modifier so it is difficult to understand how including the same requirement in ICD-10 would be a burden.
Prohibiting the denial of a claim “due solely to the use of an unspecified or inaccurate subcode” raises serious fraud and abuse concerns. The terminology “unspecified”, “inaccurate” and “subcode” are not defined and are open to a wide range of interpretations requiring virtually any intentional or unintentional coding error to be accepted for payment. Such a sweeping prohibition would eliminate the ability of Medicare to prevent coding fraud even when there was a strong indication of potential fraud or the intent to purposefully bill incorrectly. For example, if providers are exempt from specifying the side of the body, then the provider could always report the unspecified option. That means that if Medicare received two separate claims for a below the knee amputation of an unknown leg, it would have to pay both claims and not require confirmation that the second amputation was done on a different leg.
Coverage and medical necessity determinations would be difficult to make if claims are coded using unspecified or inaccurate codes. Claims data would be of questionable reliability for many non-payment purposes for which this data are used today, such as health policy decisions or assessment of quality of care. One of the core reforms in the SGR bill (H.R. 2) is a move from a payment system that rewards volume to one that rewards value. Measurement of value can not be accomplished based on unspecified or inaccurate codes.
HR 2247 requires the Secretary to take affirmative steps to assist health care providers in identifying appropriate ICD-10 codes. However, CMS as well as many professional organizations, have already provided, and continue to provide, extensive ICD-10 education to health care providers to enable them to identify proper ICD-10 codes. This education is expected to be ongoing after the ICD-10 transition. See this link for the types of ICD-10 education and resources currently available for physicians: http://coalitionforicd10.org/icd-10-resources-for-physicians/.