CMS Promises More Thorough Testing of ICD-10 Codes

February 21, 2014

Pressed by organized medicine and lawmakers alike, the Centers for Medicare and Medicaid Services (CMS) announced yesterday that it will conduct tests to see whether Medicare claims incorporating the new and controversial ICD-10 diagnostic codes actually get paid. ICD-10 stands for the International Statistical Classification of Diseases and Related Health Problems, 10th Revision.

On October 1, physicians must begin using the new codes in the claims they submit to Medicare, Medicaid, and private insurers. The American Medical Association (AMA) and other medical societies say the new codes, which are more numerous and complex than their ICD-9 predecessors, will not improve patient care much but will cost physicians tens of thousands of dollars in terms of training, implementation, software upgrades, and disrupted claims processing.

Next month, CMS will offer all physicians so-called "acknowledgement testing" that will tell them — and the billing services and claims clearinghouses they depend on — whether Medicare is able to receive their claims with ICD-10 codes. However, organized medicine has clamored for CMS to go 1 step further and conduct "end-to-end" testing of claims bearing the new codes. This kind of trial run is designed to show whether Medicare will pay a claim, and for how much. In theory, the results would help physicians spot any coding errors they commit, as well as problems in the claims pipeline between their office and Medicare. Without such testing, physicians could suffer massive payment delays, according to the AMA.

In a recent letter to the Department of Health and Human Services, the AMA's chief executive officer and executive vice president, James Madara, MD, recommended that CMS perform end-to-end testing with at least 100 different physician practices. "Any experience gained through such a testing exercise should be used to inform [the agency's] decision to adhere to the October 1, 2014, deadline," Dr. Madara wrote.

CMS even got some heat from Capitol Hill on the need for end-to-end testing. On February 11, 4 Republican senators who are also clinicians asked CMS Administrator Marilyn Tavenner whether ICD-10 testing will "allow Medicare providers to test accurate and prompt claim adjudication."

"Before either Medicare or Medicaid could conceivably transition to any new diagnostic coding method, CMS must establish clear metrics and perform system-wide tests to certify its readiness," wrote Sen. Tom Coburn, MD (R-OK); Sen. Rand Paul, MD (R-KY); Sen. John Barasso, MD (R-WY); and Sen. John Boozman, OD (R-AR).

The next day, CMS announced it would offer end-to-end testing to a small group of healthcare providers this summer. The agency said it would select providers "to represent a board cross-section of provider types, claims types, and submitter types." They would submit test claims with the new codes and receive a "remittance advice" stating how much Medicare paid.

The AMA applauded the CMS decision. However, AMA President Ardis Dee Hoven, MD, reminded the agency in a news release that the association's ultimate desire is to see the ICD-10 mandate disappear entirely. Physicians are already "struggling to keep up with many other costly federal mandates," Dr. Hoven said.

The promise of end-to-end testing also pleased the Medical Group Management Association. Susan Turney, MD, the group's president and chief executive officer, said in a news release that the testing will "decrease the potential of catastrophic cash flow disruption that could impact the ability of practices to treat patients."

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