CMS Clarifies ICD-10 Flexibility: Return of the Guidelines

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CMS Clarifies ICD-10 Flexibility: Return of the Guidelines

CMS releases a list of FAQ to insure that medical practices can produce valid codes. Renowned leaders in the industry still argue as to the effect that ICD-10 will have on healthcare as a whole.

CMS Releases FAQ for Practices

The ICD-10 wars continue…

Last week, the Centers for Medicare and Medicaid Services (CMS), released a list of FAQs in order to clarify the ICD-10 guidelines they announced on July 6th in conjunction with the American Medical Association (AMA). These guidelines, though helpful in placating some ICD-10 opponents, were still somewhat ambiguous and left providers questioning what exactly they meant.

The list from CMS addresses 13 questions. Some of the important FAQs include:

  • When will the ICD-10 Ombudsman be in place?
    • In preparation for the transition, the ICD-10 ombudsman will be appointed by October 1st, ready to assess any potential issues.
  • What qualifies as a “valid” ICD-10 code?
    • In order to be considered valid, a code must include the “full number of characters required for that code.” CMS uses the example of Hodgkin’s lymphoma, for which this code requires 5 characters: C81.00.
  • What is a “family of codes”?
    • A “family of codes” is defined as the first three characters of the code. Continuing with our Hodgkin’s lymphoma example, this requires the characters: C81.
  • Will I know whether my claim was rejected because of validity or specificity?
    • According to CMS, the reason a claim is rejected (i.e. invalid code) will be made clear to submitters.
  • Will commercial payers observe the one-year flexibility?
    • The ICD-10 flexibility guidelines will only apply to Medicare claims. Commercial payers will determine flexibilities on their own.

The rest of the FAQs can be found here at

With only two months remaining until the ICD-10 deadline, tensions are running particularly high. Several physician organizations, such as the American Academy of Orthopaedic Surgeons (AAOS), continue to strongly oppose ICD-10, maintaining their stance that it will not benefit patient care, and could actually affect it negatively.

In an article last week on Health Leaders Media, two ICD-10 experts were called on to address some of the concerns providers have had about the new coding system. Sue Bowman, the Senior Director of Coding Policy and Compliance at AHIMA, along with Rhonda Buckholtz, Vice President of ICD-10 Training and Education at AAPC, spoke about the aspects of ICD-10 that opponents are using in their fight against it.

According to Bowman, the increased specificity of the new codes is in line with current usage and terminology, whereas several ICD-9 codes are now outdated and are not able to properly reflect or describe current conditions. The specificity also addresses “disease type, site, severity, and laterality,” which are necessary for accurate coding.

Another big concern is the vast number of codes ICD-10 brings into the picture. Providers are unsure of the necessity for such a large increase. Buckholtz states that, “the amount of codes is simply not consequential.” They will only need to refer to the codes that affect patients within their specialty. Although there are 68,000+ codes, “most won’t ever use the whole book.”

Getting to the most important concern – patient care – the answer is simple: better data leads to better analysis, which leads to better outcomes.

It seems as though ICD-10 will be arriving as scheduled this year. Perhaps these answers, in addition to the CMS clarifications, will help to pacify providers.


PrognoCIS EMR is already ICD-10 compliant and prepared for users. With a simple click, users can click on the ICD-9 code in the PrognoCIS interface, quickly find the correlating ICD-10 code, and easily populate it into the patient chart. If an ICD-10 code is not filled in, the software will prompt users to add them in with an alert. All lab & radiology tests, as well as e-prescriptions, will include ICD-10 codes. To learn more about the PrognoCIS ICD-10 solution, visit our ICD-10 Hub or click here to schedule a live demonstration with one of our experts: PrognoCIS Demo.

Author: Apoorva Anupindi

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