So far the in the new ICD-10 world, CMS and private payers have been going on easy on specificity requirements. For many practices, this has been a huge help. However, if you are getting comfortable with this flexibility as the new norm then you may be in for an unpleasant surprise.
The introduction of ICD-10 has always been handled with something of a carrot and stick approach. For years CMS and congress alternated between warnings and reassurances, urging providers to thoroughly prepare while offering repeated delays and concessions about easing the requirements during the transition. The delays led many practices to think ICD-10 wasn't coming at all, causing them to put off training, testing, and making financial preparations until dangerously late, and scrambling to get ready when it was obvious no more delays were in the cards. The concessions on specificity might be creating a similar false sense of security.
It's going great! We aren't getting a huge increase in denials! We've nailed this thing! But if you're counting on payers continuing to accept codes that are only "in the family of codes" or "just make sense," and trusting your software to know things that you don't, you are living on borrowed time. More help from Congress is unlikely to arrive this time, either. "When CMS announced the flexibility rule," said Robert Tennant, senior policy advisor for the Medical Group Management Association, "interest on Capital Hill diverted almost immediately."
Barbie Hays, coding and compliance strategist for the American Academy of Family Physicians, said that she has received several calls from people asking how to code something that their EHR couldn't find. "Practices should NOT rely on their EHR," she said. If you're having this problem, Hays said you have a couple of options. "I would first recommend getting an actual hard copy of the ICD-10-CM code book. There are many vendors that sell this, such as OptumIngenix, Amazon, and the American Academy of Professional Coders (the AAFP does not endorse any particular vendor or brand). The second option— and this is not recommended, but could work in a pinch— is to Google the term and read the results." Hays adds that this last maneuver is not advisable if you are not familiar with coding convention and practices.
Bottom line is this: If things are going well for you because you are relying on your EHR and the indulgence of your payers, you might be headed for a fall. If you aren't up to speed with ICD-10, get that way as quickly as possible. You've heard it before but they weren't crying wolf last time and they aren't now.