Everything doctors should know about ICD-10 glitch

CMS has announced a glitch in the quality reporting measures brought upon by the changes in the ICD-CM (Clinical Modification) and ICD-PCS (Procedural Coding System) updates that went into affect Oct. 1.

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While CMS is a bit unclear as to exactly what the problem is, there are a few things we know: This glitch only affects fourth quarter PQRS data, the components of PQRS affected seem to be the ICD-CM (Clinical Modification) and ICD-PCS (Procedural Coding System) and it affects quality measure denominator calculations and seems to “undercount” the denominators.

“This means that for providers affected by the ICD-10 issue, they will not be subject to payment adjustments for 2017 or 2018 to eligible providers that are affected (as applicable),” says Dan Golder, DDS, principal at Impact Advisors, who has more than 30 years of regulatory and business consulting experience and specializes in strategic consulting for some of the largest healthcare organizations in the country. “Normally, these penalties under PQRS would be 2% of the Medicare fee schedule.”

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Among the groups anticipated to be most affected are the Diabetes Measures Group, Cataracts Measures Group, Oncology Measures Group, Cardiovascular Prevention Measures Group and Diabetic Retinopathy Measures Group.

What should a doctor do?

Judy Waltz, a partner and health lawyer with Foley & Lardner LLP, notes physicians should be sure they have updated their systems to use the latest version of ICD-10 and that all their physicians and eligible professionals are using the latest and most specific codes, and/or providing adequate documentation to support the assignment of codes. 

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“Physicians should also confirm that they have signed up for PQRS so they don’t get a penalty simply for not reporting,” she says in an email. “By this point, their diagnostic data for 2016 Q4 has probably been input, and assuming it was input accurately with the latest version of ICD-10, there shouldn’t be a need to take any affirmative steps, although it is always good to do some spot monitoring to be sure that coding and documentation are up-to-date with latest requirements.”

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Golder notes that physicians need to continue to report PQRS measures as they would normally. If their denominator scores are low (i.e. they are unexpectedly under 20 and therefore are likely to have been affected by the ICD-10 glitch) they should still report these low scores.

“CMS will independently analyze the data, and if CMS concludes that the ICD-10 glitch is the cause, they will not assess payment adjustments for the affected providers,” he says. “If providers receive a payment adjustment and believe it is due to the ICD-10-CM code update, they will have the option to submit a request for an informal review of the payment adjustment from CMS.”

When the PQRS adjustments are issued, Waltz agrees that doctors should scrutinize them carefully. “If physicians get hit with a penalty on their quality metrics for 2018 as a result of this issue, they should complain to CMS,” she says.

George B. Breen, an attorney with Epstein Becker & Green and chair of the firm’s National Health Care and Life Sciences Practice Steering Committee, says physicians should be closely following-and implementing-any changes to the ICD-10 coding system.

“It is critical that practices regularly train billing staff to ensure the most accurate reporting possible,” he says. “These changes often call for training of both clinical and billing staff in order to make sure that coding is in sync with the intent and content of the medical record.”

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“Plainly, the increased specificity provided through ICD-10 allows the government to more closely analyze claims submitted by physicians,” Breen says. “These glitches should serve as a reminder that coding accuracy is critical and can be the first line of defense, particularly against False Claims Act cases pursued by the government and qui tam relators, who increasingly contend that services billed for were not provided, or not provided as billed.”

Correcting the glitches

As of mid-January, CMS has not offered details on what is being done to correct the glitch, although they have stated they will be releasing an addendum later this year addressing relevant updates to ICD-10 value sets for The Merit-based Incentive Payment System. This will ensure that MIPS calculations beginning in 2017 are not affected by the same problem.

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Presumably, this won’t be a recurring problem, since as CMS describes it, the glitch resulted from a backlog of revisions that it had held up while trying to make the transition to ICD-10 less painful.