ICD-10: Who’s in the Family of Codes?

CMS has said it will not deny or audit claims just for specificity for one year after implementation of ICD-10 as long as the code is from the appropriate family of ICD-10 codes. But it has not defined what a family of codes is.

This article originally appeared in ICD-10 Trainer

Remember those friends and family cell phone plans where you didn’t use minutes if you called people in your circle? You had to pick who you wanted in your group and they had to pick you. It was very confusing trying to figure out who was in the family and who wasn’t.

CMS created the same kind of confusion last week when it basically cut a deal with the American Medical Association (AMA). The AMA, you may recall, has been very vocally opposed to ICD-10 being implemented in any way, shape, or form.

To get AMA to cease and desist its defiance, CMS gave AMA something it wanted: no penalties for some coding errors and advanced payments if the technology goes kerflooey.

I can totally understand advancing payments if the system doesn’t work. That’s pretty straightforward. The physician gets paid on time and doesn’t have to worry about going under because of something he or she can’t control. The physicians will have to repay the advanced payment once the system is running smoothly, so they aren’t getting extra money. They just get a hedge against a Y2K meltdown.

The confusing part of the pact is the hold harmless for miscoding. AMA initially wanted physicians to get a pass on coding errors for two years. I’m pretty sure AMA knew that wasn’t going to fly, but when you negotiate, you always start high.

In the final deal, CMS stated auditors will not deny a claim “based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.”

CMS does not, however, define a family of codes. Is it a category of codes, such as S00, superficial injury of head? That could be interesting. S00 has nine subcategories of codes, each with their own subcategories.

CMS: No ICD-10 Audit Claims for Specificity in Year One

Or does CMS mean those subcategories, say S00.4, superficial injury of ear? Again, S00.4 includes eight subcategories with their own subcategories.

Maybe CMS considers a family to be the smallest group of subcategories. So under S00, we could go all the way down to S00.46-, insect bite (nonvenomous) of ear as a family. That would give us three codes in the family:

461, insect bite (nonvenomous) of right ear
462, insect bite (nonvenomous) of left ear
469, insect bite (nonvenomous) of unspecified ear

That seems reasonable. The only missing information is the laterality. Not a huge deal, but really the physician should be documenting it. Maybe the coder just couldn’t find it or was in a hurry and defaulted to unspecified.

Source: http://healthleadersmedia.com/content.cfm?topic=TEC&content_id=318822