A Gift from CMS: ICD-10 Medical Necessity Policies

In case you missed it, on September 14, 2012, CMS released Transmittal 1122, CR 7818 titled “International Classification of Diseases (ICD)-10 Conversion from ICD-9 and Related Code Infrastructure of the Medicare Shared System as They Relate to CMS National Coverage Determinations (NCDs) (CR 1 0f 3) (ICD-10) .” Whew.

Upon initial glance, you might think this does not look like any kind of present you would be interested in receiving. But once you read it, you will realize it’s a real gift for all those concerned with medical necessity, compliance, and ICD-10 translations.  The real ‘jewel’ is this statement: “the purpose of this change request (CR) is to both create and update national coverage determination (NCD) hard-coded shared system edits that contain ICD-9 diagnosis codes with comparable ICD-10 diagnosis codes plus all the associated coding infrastructure such as procedure codes, HCPCS/CPT codes, denial messages, frequency edit. POS/TOB/provider specialties, etc.”

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My Take

What a great gift! I know, I know – as my daughter would say, my world is significantly small if I am excited about new codes in National Coverage Determination policies.  But c’mon – this is awesome. Remember the NCDs you’ve looked at in the past that were so vague you wanted to cry? How can anyone be compliant if the instructions were so, well, lacking direction?  According to the Transmittal, now you will see the ICD-10 translated NCDs (when released) with codes – lots of codes. The newly added data will help providers determine (in black and white, so to speak) what is expected.

How nice will it be to be able to check a policy and search for the specific code(s) you are considering? Covered? Yep – or not – clearly delineated in the NCD.  Plus, a lot of them will have the codes you need to include on your claims to pass the adjudication systems, like modifiers and revenue codes in addition to a much more specific list of diagnosis codes, thanks to ICD-10.  And, you will clearly see the new diagnoses codes CMS expects on the claim to support medical necessity.

You’re right: the NCDs will not cover every clinical circumstance. No utilization policy authored by any payer can, and there will be exceptions, but this is a leap forward in the right direction in my honest opinion. And yes, they will be a work-in-progress as codes change and policies are updated, but CMS has gone a long way to make their medical necessity policies a lot more transparent. Now, what will you do with the lovely new data when you get it?

Barbara Aubry is a Regulatory Analyst with 3M Health Information Systems.