CMS Issues ICD-9 to ICD-10 Transition Claims Instructions

CMS published a special MedLearn Matters article addressing ICD-9 to ICD-10 transition claims instructions. The article SE1325, addresses institutional provider which includes home health and hospice providers. Providers will be required to split claims so that all ICD-9 codes remain on one claim with Dates of Service (DOS) through September 30, 2014 and all ICD-10 codes placed on the other claim with DOS beginning October 1, 2014 and later. While the processing requirements for hospice should be clean because they bill on a monthly basis, home health has several challenges and issues to clarify.

Since home health does episodic billing, will all Medicare and Medicaid patients be required to be discharged and readmitted at their first billable visit on or after October 1, 2014? Under important details in the article, Note 1 states that “creating multiple/interim claims on a single encounter is not a new concept and that these instructions will apply to relatively few claims that span this single implementation date (October 1, 2014) will be impacted.” This could impact 1/6th of all claims for 2014 impacting over 1 million Medicare episodes alone, so this would not affect a “relatively few claims”.

There is a potential that CMS would fall back to the logic stated in Note 2 and treat the episode as a single service; however not likely because of the problems this causes. If an episode starts before October 1, 2014 and the resumption of care is completed after, which code set would you use? ICD-10 should be used, then the diagnosis data will not be consistent across the episode. If ICD-9 is used, then agencies will be required to code certain claims under each of the ICD data sets during an extended period. This would result in increased confusion amongst coders and potential errors.

CMS also needs to clarify which OASIS data set (M item), is tied to the DOS; M0030 (Start of Care (SOC) Date) or M0090 (Date Assessment Completed). CMS has implemented different program changes based on each item depending on the circumstance. M0030 makes sense except in the case of recertification, since that is not used. M0090 can be beneficial, as it allows a few days of wiggle room around the October 1st implementation date. In the case of SOC, this would allow for SOC to be completed as early as September 27th, considering that October 1st will occur mid-week. This could be helpful especially if all Medicare and Medicaid patients will need to be discharged and readmitted.

Either scenario would not be pleasant. Ideally, there should be a 60 day window on either side of October 1, 2014 to allow for entering ICD-9 or ICD-10 codes. This would put the burden on the government. The agencies would have the ability to do what is best for their staff and the patients. The government would need to handle processing both types of claims during this time.  This would decrease the burden on the agencies.  There has not been any talk of this and it does appear the burden will fall onto the agencies.