Practice Management, Inc.

By Holly Louie, RN, CHBME

The story that I am going to relate could borrow a line from the movie When Harry Met Sally.  Sally is sobbing and says she is going to be 4o.  When Harry asks when, Sally responds, “Some day!”  And that is our punch line to this story.

There has been so much talk about how smoothly ICD-10 has gone.  No big surprises, no significant increase in claims denials, cash flow not significantly disrupted.  But wait!  Let’s talk about the forthcoming CMS announcement about just one National Coverage Decision absolute disaster.  This is not an isolated problem, but the best example I know of how bad it can get, how quickly it can snowball and how long providers are expected to just wait for payments.

On February 5, 2015, CMS issued a National Coverage Determination (NCD) for screening for lung cancer with low dose computed tomography (LDCT).  There is no doubt this was a very good decision.  However, at that time, CMS did not provide any instructions regarding CPT, HCPCS or diagnosis codes that would be covered under this policy, or any methodology to bill for the services. That would be released, “some day”.  In spite of pressure from numerous organizations, the HCPCS code was not released until the 2016 fee schedule was published in the final quarter of 2015.  The date providers could begin billing the code was January 1, 2016.  It was bad enough to wait almost a full year to bill for all the legitimate, medically necessary services provided to Medicare beneficiaries, but the other shoe was about to drop.

For those not in the radiology space, the policy covers people who smoked in the past or who are current smokers, as long as other specified criteria are met.  When the covered diagnosis codes in ICD-9 and ICD-10 were published in October, it was immediately obvious that CMS had completely omitted the diagnosis codes for current smokers.  (See MM9246)  In spite of the fact that this error was brought to the attention of CMS, and they agreed there was a significant omission, they responded that it would be addressed at their earliest convenience.  This omission was incorporated in the applicable Medicare manuals, NCD and other transmittals and instructions.

Communications with CMS over the past week have resulted in the promise of a forthcoming transmittal that will explain how and when corrections will be made.  Because NCDs are only updated quarterly and because CMS was already working on the quarterly updates well into 2016, the earliest we can expect corrections for claims is in the July 2016 publication, possibly to be implemented in October.  Ladies and Gentlemen, that is 1 full year plus either 5 or 8 months before any correct adjudication will begin.  Will claims need to be resubmitted or will they be reprocessed?  There will need to be overrides for timely filing and other operational realities.  Will the providers also have to bear that burden?

No one expected CMS to implement the myriad changes required by ICD-10 error free.  Mistakes happen.  But this system is broken and it needs to be fixed.  Once a coverage decision has been made, the mechanism for submitting claims and receiving correct payment should be in place before issuing notices.  Holding claims for 11 months is not ok.  Correction of egregious, or even minor errors, should certainly not take 6 months or longer.  Prompt interim instructions should be implemented to allow claims submission and correct adjudication and payment as soon as the error is known.

It seems to me we have a double standard.  When a Medicare contractor wants something there is a very short time line to respond or suffer the consequences.  When CMS has errors, there is apparently no clock for resolution or concern for the providers who cannot get paid for treating Medicare beneficiaries.  In this case, we can expect payment, “some day.”

Holly Louie, RN, CHBME, is the compliance officer for Practice Management Inc. and the 2016 HBMA president.