Beginning October 1, 2014, CMS will start using ICD-10 codes for diagnostic and billing purposes. Currently, ICD-9 codes are used. CMS will accept ICD-10 codes for all claim input and DDE files submitted on or after October 1, 2014. Any production files submitted with ICD-10 codes prior to October 1, 2014, will be rejected. However, RREs may submit test files with ICD-10 codes beginning October 1, 2013. An alert regarding ICD-10 and ICD-9 codes which are excluded from reporting was recently published by CMS. A copy of the alert can be viewed at http://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Non-Group-Health-Plans/Downloads/New-Downloads/Alert-%E2%80%93-Excluded-ICD-9-CM-and-ICD-10-CM-Diagnosis-Codes.pdf.
ICD-10 codes will be required for file submissions with a CMS date of incident on or after April 1, 2015. For file submissions with a CMS date of incident prior to April 1, 2015, RREs may continue to use ICD-9 codes but are encouraged to use ICD-10 codes for files submitted beginning October 1, 2014.
CMS discussed that an RRE may report termination of ORM if the primary care physician provides an attestation confirming that it is not reasonably expected that further treatment will be needed for the injury at issue. RREs do not provide the physician letter to CMS for Section 111 reporting purposes but should maintain the letter in their file. It is not necessary to obtain such a physician attestation if termination of ORM is reported because the RRE’s legal responsibility for payment for treatment has ended.
CMS generally addressed situations in which Medicare incorrectly denies payment for unrelated treatment due to an open ORM record. In many cases where an RRE has reported ORM for a particular injury, Medicare has been initially denying payment for completely unrelated treatment. CMS indicated that they are working to correct these issues and reiterated that in such situations the beneficiary has a right to file an appeal. Although CMS noted that they do not have a definite solution for cases in which medical providers refuse to provide treatment to beneficiaries because Medicare has been incorrectly denying payment in the past, they indicated that the beneficiary may be able to resolve the issue by referring the medical provider to the recent CMS MedLearn article addressing the issue. CMS also suggested that it may be helpful for an RRE to provide the beneficiary with a letter to present to the medical provider explaining that ORM has only been reported for the injury at issue.
CMS confirmed that an Alert addressing amended complaints should be issued in the near future and possibly in the next two weeks. Although CMS did not specify what the Alert would state, we expect that the Alert will address liability and no-fault cases in which a complaint initially alleges an injury, ingestion, or exposure on or after December 5, 1980, and the complaint is subsequently amended to only allege an injury, ingestion, or exposure prior to December 5, 1980. In general, RREs are not required to report liability or no-fault cases when the case does not involve an actual or alleged injury, ingestion, or exposure prior to December 5, 1980, and no such injury, ingestion, or exposure is specifically released.
CMS indicated that they are considering creating exceptions for reporting cases involving certain types of insurance when NOINJ would otherwise be reported. NOINJ is reported in cases when there is no allegation of a situation involving medical care or a physical or mental injury and the settlement, judgement, award, or other payment releases or has the effect of releasing medicals. The specific types of insurance CMS listed as being considered for a reporting exception are employment practices liability insurance, directors and officers liability insurance, professional liability insurance other than medical malpractice insurance, fiduciary liability insurance, and errors and omissions insurance. CMS also indicated that they are considering creating an exception for cases involving loss of consortium when NOINJ would otherwise be reported.
CMS discussed that an Advance Notice of Proposed Rulemaking is forthcoming to solicit comments on proposed criteria for the imposition of Section 111 reporting penalties, as required by the SMART Act. Although CMS indicated that they could not currently comment on the Advance Notice of Proposed Rulemaking, it is expected to be published in September 2013. We will keep you informed of any developments in CMS’s issuance of the Advance Notice of Proposed Rulemaking and implementation of the SMART Act.
