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MACs Revise LCDs Due to ICD-10 Errors Reported After Transition Date

  • by Margaret Klasa DC, APN BC
  • Nov 19, 2015, 17:04 PM

HMACs ICD-10 Claim Processing Errors Tied to LCDsThe October 1, 2015, ICD-10 mandated code change caused some issues for 8 of the 12 Medicare Jurisdictions that impact at least 32 states. Some of the Medicare Administrative Contractors (MACs) relied on the General Equivalence Mappings (GEMs) to map ICD-9 to ICD-10 codes, which was insufficient for the Local Coverage Determinations (LCDs). Most of the GEM mappings provide unspecified codes and where ICD-9 LCDs relied on exact codes the GEM mappings are unspecified. The announcement by the Centers for Medicare & Medicaid Services (CMS) about using a valid code from the right code family did not preclude to LCDs, where specific code requirements are listed, may have also lead to the confusion of providers submitting unspecified codes.

The 8 MACs reported this past month that they had at least one error each for mammogram codes G0204 and G0206, hepatitis B, routine eye exams, flu administration, pneumococcal vaccine codes 90670 and 90732, and 10 states have had their claims held up because of high volume and national payment. Florida, Puerto Rico and U.S. Virgin Island are holding claims for injection code J0811 which also has a high national bill rate.
 
The good news is that the payers will ultimately correct their files and claims will be paid, and providers whose claims are held for more than 14 days, may be entitled to interest on those held claims. Just as providers are making documentation and system related changes due to ICD-10, so are the payers. Often times, MAC LCD policies are being revised and added to as the contractors correct these errors. Keeping a close eye on LCD policies will be a key on both provider and payer sides.

What resources are available in order to safeguard against submitting codes that are no longer in the Medicare LCD policy? Context4 Healthcare, a leader in claim compliance, developed the ClaimsEditor® solution to help providers, hospitals, and health systems gain visibility into problems and actionable insight for resolution before problems leave the business office. In this case, there are specific Local Coverage Determinations (LCDs) that are checked and referenced by specific rules within ClaimsEditor, so providers are always up-to-date with the most current policies and regulations. With thousands of rules and millions of edit combinations updated weekly, ClaimsEditor is SaaS-based with real-time web services for automated update options.

In addition, those who utilize ClaimsEditor can access real-time Medicare fee schedules and Context's DecisionPoint™ Health Payment System UCR fee data derived from billions of provider charges and updated twice per year. This industry-leading capability will go a long way in ensuring claim compliance while reducing claim denial rates.

 

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MACs Revise LCDs Due to ICD-10 Errors Reported After Transition Date

  • by Margaret Klasa DC, APN BC
  • Nov 19, 2015, 17:04 PM

HMACs ICD-10 Claim Processing Errors Tied to LCDsThe October 1, 2015, ICD-10 mandated code change caused some issues for 8 of the 12 Medicare Jurisdictions that impact at least 32 states. Some of the Medicare Administrative Contractors (MACs) relied on the General Equivalence Mappings (GEMs) to map ICD-9 to ICD-10 codes, which was insufficient for the Local Coverage Determinations (LCDs). Most of the GEM mappings provide unspecified codes and where ICD-9 LCDs relied on exact codes the GEM mappings are unspecified. The announcement by the Centers for Medicare & Medicaid Services (CMS) about using a valid code from the right code family did not preclude to LCDs, where specific code requirements are listed, may have also lead to the confusion of providers submitting unspecified codes.

The 8 MACs reported this past month that they had at least one error each for mammogram codes G0204 and G0206, hepatitis B, routine eye exams, flu administration, pneumococcal vaccine codes 90670 and 90732, and 10 states have had their claims held up because of high volume and national payment. Florida, Puerto Rico and U.S. Virgin Island are holding claims for injection code J0811 which also has a high national bill rate.
 
The good news is that the payers will ultimately correct their files and claims will be paid, and providers whose claims are held for more than 14 days, may be entitled to interest on those held claims. Just as providers are making documentation and system related changes due to ICD-10, so are the payers. Often times, MAC LCD policies are being revised and added to as the contractors correct these errors. Keeping a close eye on LCD policies will be a key on both provider and payer sides.

What resources are available in order to safeguard against submitting codes that are no longer in the Medicare LCD policy? Context4 Healthcare, a leader in claim compliance, developed the ClaimsEditor® solution to help providers, hospitals, and health systems gain visibility into problems and actionable insight for resolution before problems leave the business office. In this case, there are specific Local Coverage Determinations (LCDs) that are checked and referenced by specific rules within ClaimsEditor, so providers are always up-to-date with the most current policies and regulations. With thousands of rules and millions of edit combinations updated weekly, ClaimsEditor is SaaS-based with real-time web services for automated update options.

In addition, those who utilize ClaimsEditor can access real-time Medicare fee schedules and Context's DecisionPoint™ Health Payment System UCR fee data derived from billions of provider charges and updated twice per year. This industry-leading capability will go a long way in ensuring claim compliance while reducing claim denial rates.

 

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