CMS and the AMA Make Important Implementation Announcement with FAQ’s to Help Providers Get Ready Fo

Frequently Asked Questions

Q1. What if I run into a problem with the transition to ICD-10 on or after October 1st 2015?

A1. CMS understands that moving to ICD-10 is bringing significant changes to the provider

community. CMS will set up a communication and collaboration center for monitoring the

implementation of ICD-10. This center will quickly identify and initiate resolution of issues that

arise as a result of the transition to ICD-10. As part of the center, CMS will have an ICD-10

Ombudsman to help receive and triage physician and provider issues. The Ombudsman will

work closely with representatives in CMS’s regional offices to address physicians’ concerns. As

we get closer to the October 1, 2015, compliance date, CMS will issue guidance about how to

submit issues to the Ombudsman.

Q2. What happens if I use the wrong ICD-10 code, will my claim be denied?

A2. While diagnosis coding to the correct level of specificity is the goal for all claims, 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. However, a valid ICD-10 code will be required on all claims starting on October 1,

2015. It is possible a claim could be chosen for review for reasons other than the specificity of

the ICD-10 code and the claim would continue to be reviewed for these reasons. This policy will

be adopted by the Medicare Administrative Contractors, the Recovery Audit Contractors, the

Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor.

Q3. What happens if I use the wrong ICD-10 code for quality reporting? Will Medicare

deny an informal review request?

A3. For all quality reporting completed for program year 2015 Medicare clinical quality data

review contractors will not subject physicians or other Eligible Professionals (EP) to the

Physician Quality Reporting System (PQRS), Value Based Modifier (VBM), or Meaningful Use


(MU) penalty during primary source verification or auditing related to the additional specificity

of the ICD-10 diagnosis code, as long as the physician/EP used a code from the correct family of

codes. Furthermore, an EP will not be subjected to a penalty if CMS experiences difficulty

calculating the quality scores for PQRS, VBM, or MU due to the transition to ICD-10 codes.

CMS will not deny any informal review request based on 2015 quality measures if it is found

that the EP submitted the requisite number/type of measures and appropriate domains on the

specified number/percentage of patients, and the EP’s only error(s) is/are related to the

specificity of the ICD-10 diagnosis code (as long as the physician/EP used a code from the

correct family of codes).

CMS will continue to monitor the implementation and adjust the timeframe if needed.

Q4. What is advanced payment and how can I access this if needed?

A4. When the Part B Medicare Contractors are unable to process claims within established time

limits because of administrative problems, such as contractor system malfunction or

implementation problems, an advance payment may be available. An advance payment is a

conditional partial payment, which requires repayment, and may be issued when the conditions

described in CMS regulations at 42 CFR Section 421.214 are met.

To apply for an advance payment, the Medicare physician/supplier is required to submit the

request to their appropriate Medicare Administrative Contractor (MAC). Should there be

Medicare systems issues that interfere with claims processing, CMS and the MACs will post

information on how to access advance payments. CMS does not have the authority to make

advance payments in the case where a physician is unable to submit a valid claim for services


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