CMS Suspends Payment on Certain ICD-10 Claims

CMS Systems Not Ready for All NCDs and LCDs

We may be seeing one of the first latent indicators of the financial impact of ICD-10 with today’s announcement. CMS stated in a November 20th 2015 email that its systems are being updated to accommodate ICD-10 NCDs and LCDs.  This also resulted in “temporary” suspensions of payments for LCDs.  CMS states, “Claims affected by these edits were temporarily suspended.”

Despite promises from CMS that payments would be processed even if there were deficiencies in how the claims are submitted for Medicare Part B providers, this may be the first significant area where CMS is unable to fulfill that commitment.  CMS stated that a permanent fix won’t be ready for about 40 days.

According to an FAQ from CMS published July 6, 2015 and updated September 22, 2015:

“Question 7:
National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) often indicate specific diagnosis codes are required. Does the recent Guidance mean the published NCDs and LCDs will be changed to include families of codes rather than specific
codes?
Answer 7:
No. As stated in the CMS’ Guidance, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review 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 of codes. The Medicare review contractors include the Medicare Administrative Contractors, the Recovery Auditors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor.”

CMS Systems Impacted

The U.S. Centers for Medicare and Medicaid (CMS) published clarifications regarding National Coverage Determination (NCD) and Local Coverage Determination (LCD) policies. Medicare national and local coverage policies are translated for the new medical coding standard, International Classification of Diseases, version 10 (ICD-10), and to receive payment, providers must bill using ICD-10 codes for services rendered on or after October 1, 2015.

This impacts  Medicare Coverage Database (MCD) which contains all NCDs and LCDs, local articles, and proposed NCD decisions. The database also includes several other types of National Coverage policy related documents, including National Coverage Analyses (NCAs), Coding Analyses for Labs (CALs), Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) proceedings, and Medicare coverage guidance documents.  The deficiency was reported by Medicare Administrative Contractors.

National Coverage Determinations Require Interim Fix to CMS Systems

CMS stated, “Interim solutions are currently in place to permit appropriate claims payment. In most cases, claims were automatically reprocessed, and no action is required. A permanent systems update will be in place by January 4, 2016.”  Information about specific claim types and the reprocessing of claims is available on your Medicare Administrative Contractor (MAC) website.

Local Coverage Determinations and Claim Suspensions

CMS explained in the email that, “… after implementation, some Medicare Administrative Contractors (MACs) identified LCDs that needed further refinements for ICD-10 diagnosis codes. Claims affected by these edits were temporarily suspended and automatically reprocessed. Curiously, CMS stated, “No action is required. Questions about specific LCDs should be directed to the appropriate MAC.”

Expected Legal and Fiscal Impacts to Health Care Providers

This potentially impacts hundreds of $millions of health care claims.  Health care providers should have heeded early industry advice to take out a line of credit as a hedge against revenue disruption.  Quasi government entities such as MACs who are fiscal intermediaries as well as Medicare Advantage plans that have a fiduciary duty to manage funds on behalf of the U.S. Government’s HHS and CMS departments will have to evaluate their payment policies.  State workers compensation funds, third party liability claims, and State Medicaids may also be impacted.

Michael F. Arrigo

Michael Arrigo, an expert witness, and healthcare executive, brings four decades of experience in the software, financial services, and healthcare industries. In 2000, Mr. Arrigo founded No World Borders, a healthcare data, regulations, and economics firm with clients in the pharmaceutical, medical device, hospital, surgical center, physician group, diagnostic imaging, genetic testing, health I.T., and health insurance markets. His expertise spans the federal health programs Medicare and Medicaid and private insurance. He advises Medicare Advantage Organizations that provide health insurance under Part C of the Medicare Act. Mr. Arrigo serves as an expert witness regarding medical coding and billing, fraud damages, and electronic health record software for the U.S. Department of Justice. He has valued well over $1 billion in medical billings in personal injury liens, malpractice, and insurance fraud cases. The U.S. Court of Appeals considered Mr. Arrigo's opinion regarding loss amounts, vacating, and remanding sentencing in a fraud case. Mr. Arrigo provides expertise in the Medicare Secondary Payer Act, Medicare LCDs, anti-trust litigation, medical intellectual property and trade secrets, HIPAA privacy, health care electronic claim data Standards, physician compensation, Anti-Kickback Statute, Stark law, the Affordable Care Act, False Claims Act, and the ARRA HITECH Act. Arrigo advises investors on merger and acquisition (M&A) diligence in the healthcare industry on transactions cumulatively valued at over $1 billion. Mr. Arrigo spent over ten years in Silicon Valley software firms in roles from Product Manager to CEO. He was product manager for a leading-edge database technology joint venture that became commercialized as Microsoft SQL Server, Vice President of Marketing for a software company when it grew from under $2 million in revenue to a $50 million acquisition by a company now merged into Cincom Systems, hired by private equity investors to serve as Vice President of Marketing for a secure email software company until its acquisition and multi $million investor exit by a company now merged into Axway Software S.A. (Euronext: AXW.PA), and CEO of one of the first cloud-based billing software companies, licensing its technology to Citrix Systems (NASDAQ: CTXS). Later, before entering the healthcare industry, he joined Fortune 500 company Fidelity National Financial (NYSE: FNF) as a Vice President, overseeing eCommerce solutions for the mortgage banking industry. While serving as a Vice President at Fortune 500 company First American Financial (NYSE: FAF), he oversaw eCommerce and regulatory compliance technology initiatives for the top ten mortgage banks and led the Sarbanes Oxley Act Section 302 internal controls I.T. audit for the company, supporting Section 404 of the Sarbanes Oxley Act. Mr. Arrigo earned his Bachelor of Science in Business Administration from the University of Southern California. Before that, he studied computer science, statistics, and economics at the University of California, Irvine. His post-graduate studies include biomedical ethics at Harvard Medical School, biomedical informatics at Stanford Medical School, blockchain and crypto-economics at the Massachusetts Institute of Technology, and training as a Certified Professional Medical Auditor (CPMA). Mr. Arrigo is qualified to serve as a director due to his experience in healthcare data, regulations, and economics, his leadership roles in software and financial services public companies, and his healthcare M&A diligence and public company regulatory experience. Mr. Arrigo is quoted in The Wall Street Journal, Fortune Magazine, Kaiser Health News, Consumer Affairs, National Public Radio (NPR), NBC News Houston, USA Today / Milwaukee Journal Sentinel, Medical Economics, Capitol ForumThe Daily Beast, the Lund Report, Inside Higher Ed, New England Psychologist, and other press and media outlets. He authored a peer-reviewed article regarding clinical documentation quality to support accurate medical coding, billing, and good patient care, published by Healthcare Financial Management Association (HFMA) and published in Healthcare I.T. News. Mr. Arrigo serves as a member of the board of directors of a publicly traded company in the healthcare and data analytics industry, where his duties include: member, audit committee; chair, compensation committee; member, special committee.