Aug. 7, 2015: Other payers position’s on CMS’ relaxed ICD-10-CM rules

 Dr. Joseph R. Maldonado Twitter_logo_blue1
August 7, 2015
Volume 15, Number 30

Dear Colleagues:

Earlier this year, the Commonwealth Fund reported the findings of its 2014 Biennial Health Insurance Survey. It subsequently published a brief on the growing trend of Americans purchasing inadequate insurance coverage. The brief notes that the “share of continuously insured adults with high deductibles has tripled, rising from 3 percent in 2003 to 11 percent in 2014”.   It further reports that 23 percent of 19-to-64 year-old adults (31 million) had high out-of-pocket costs or deductibles and were as such, underinsured.  This stands in contrast to the 17 million that were previously uninsured who now have insurance (regardless of its adequacy).  The Commonwealth Fund sounds the alarm calling attention to the problem of the underinsured.

This comes as no surprise to New York’s physicians. Many of MSSNY’s members have been sounding this alarm for several years. The numbers of individuals who, prior to the ACA, had no health insurance has decreased.  But the number of those previously insured with higher deductible plans has increased.  This poses a tremendous burden on both patients and physicians.  The Commonwealth Fund brief notes that more such patients are seeing their credit ratings drop, experiencing bankruptcy and incurring credit card debt to pay their deductibles.

Physicians are required by law to make a reasonable effort to collect payment from patients.  We cannot simply write off the physician charges as bad debt.  For the patient who does not meet their high deductible, failure to meet their deductible obligation to their physician threatens future access to care (57% of patients with a high deductible plan reported at least one cost-related access problem).  Many physicians complain to me about their dilemma in trying to render necessary care–despite the patient’s inabilities to meet their deductible–while maintaining viable practices.  For many, opting out of high-deductible plans or opting out of a particular carrier is the only option for their financial viability.

If we truly want to improve access to care for all Americans, we must design health policies that ensure that ALL Americans have access to care.  This means designing and promoting healthcare insurance products with affordable deductibles that encourage patients to seek care and ensure a full cadre of participating physicians to meet their needs.

Failure to address this problem will destroy America’s middle class and shift the demographics of poor health outcomes from America’s poor to America’s middle class.

Joseph Maldonado, M.D, MSc, MBA, DipEBHC
MSSNY President

Please send your comments to


SIM/SHIP Listening Tour Sessions in NYC, LI and Albany Next Week: This is Your Opportunity to Participate!
The Department of Health is conducting a Listening Tour to receive input on its design and rollout of the State Innovation Model/State Health Innovation Plan (SIM/SHIP) which will facilitate accelerated delivery system transformation to provide better care at lower cost. Several of MSSNY leaders participated in the SIM listening Tour sessions held last month in Buffalo, Rochester and Syracuse. The SIM/SHIP Tour will hold sessions for physician leaders in NYC, LI and Albany next week! This is your opportunity to participate!

This is a very important opportunity for physicians to provide feedback to the Department of Health on the State Innovation Model (SIM) and the various aspects of the Advanced Primary Care Model. In order to ensure that there is input from our members, you are being invited to participate.

The meeting locations are listed below.  If you are interested in participating, please contact Liz Dears at Due to space limitations registration is required.

NYC Provider Listening Session:

Date:     8/10/15

Time:    10:00 am – noon

Venue:  United Hospital Fund

1411 Broadway, 12th Floor
New York, NY 10018

Long Island Provider Listening Session:

Date:     8/11/15

Time:    10:00 am – noon

Venue: Medical Liability Mutual Insurance Company (MLMIC)

90 Merrick Avenue – 7th Floor
East Meadow, New York 11554

 Albany Provider Listening Session:

Date:    8/12/15

Time:    10 am – noon

Venue:  MSSNY

99 Washington Avenue, Ste 408

Albany, NY 12210 

MSSNY Survey on EHR Usage and Functionality Shows Continued Level of Frustration with EHR technology- Physicians Who Haven’t Yet Done So, Urged to Complete Survey
Preliminary response to MSSNY’s survey on EHR usage and functionality are consistent with results of other surveys which show a level of dissatisfaction with regard to EHR systems.

While 78% of respondents to MSSNY’s survey are using or plan within two years to use EHRs in their practice or at their hospital, 53% stated that they are either disappointed or very disappointed with their EHR. Notably, 38% of the respondents stated that their EHRs cannot generate routine reports to help manage their patient population, like diabetics, hypertension or ad hoc reports like finding patients due for a flu shot and 29% replied that their EHRs do not support meaningful use 2 or provide guidance on how to achieve MU-2. 56% responded that their EHR did not have prompts to notify them of gaps in patient care. Of the 45% of physicians who stated that they were currently participating in pay for performance (P4P) programs that require reporting from their EHRs, 32% stated that their EHR did not give adequate support to collect data to support their P4P program.

Many stated that they or their staff either manually aggregated the data or purchased additional software to do so. 75% of the respondents did indicate that they were e-prescribing either non-controlled substances only (46%) or both non-controlled and controlled substances (29%). Of those who were not e-scribing, a majority (66%) indicated that the delay in the implementation of the law was the primary reason why they were not yet e-scribing. With regard to educational programming, 46% of respondents stated that they would like more information on three topics: the Delivery System Reform Incentive Program (DSRIP) and how it will affect my practice;  the State Health Innovations Plan and how will it affect my practice; and how to get the most out of the data in your EHR. Other educational programs thought to be of value to respondents included: Value Based Purchasing; What is It and how can physicians position themselves to maximize payment (40%) and Practice transformation; what does this accomplish for the typical physician practice (33%).

Physicians are encouraged, if they haven’t yet done so, to complete the survey by clicking here.

Contact Governor Cuomo to Help Assure “Prescriber Prevails” Protections
Physicians are urged to contact the Governor’s office in support of legislation (A.7208, Gottfried/S.4893, Hannon) that would strengthen “prescriber prevails” protections in Medicaid managed care.  The bill passed the Assembly and Senate before the end of Session, and was just sent to the Governor.

The bill would reduce the hassles physicians are experiencing in trying to assure their patients insured by MMC plans can receive necessary anti-depressant, anti-psychotic, anti-rejection, epilepsy, seizure, endocrine, hematologist and immunologic medications.  In 2012, the Legislature passed a law to assure “prescriber prevails” protection for these drug classes similar to the Medicaid fee for service program, but a quirk in the law has given MMC plans the ability to unfairly delay approval, undermining the intent of the law.  This legislation would help to assure patients can receive these medications with a minimum of hassles.

The Governor has until next Friday, August 14, to act on the bill, so contacts must be made in the next week. A letter can be sent from the MSSNY Grassroots site here or a call can be made to 518-362-8946.

Legionnaires’ Outbreak Has Infected 100, Killed 10
As of Thursday, the Legionnaires’ disease outbreak in New York City has sickened at least 100 individuals. Ninety-two people have been hospitalized and 48 have been treated for the disease and discharged, according to the city’s Department of Health and Mental Hygiene. New York City Health Commissioner Dr. Mary T. Bassett issued a directive Thursday calling for all New York City buildings with water-cooling towers to be accessed and disinfected within the next two weeks. Today, Mayor Bill de Blasio is expected to provide details of a legislative plan he announced this week that is meant to tighten regulation of the cooling towers.

CMS Revised Guidelines Regarding ICD-10 Flexibilities
CMS has revised their FAQs on ICD 10 coding, which are consistent with the original announcement regarding flexibility when the right “family of codes” are submitted. Revisions were made to questions 3 and 5. We are also working with CMS to develop a version of the FAQs that is specifically geared for physicians (attached document is aimed at multiple audiences—Medicare contractors, CMS regional offices) and to be sure that a teleconference planned for late August reflects the initial joint announcement issued on July 6.

ICD-10 News from Non-Medicare Payers
Regina McNally, VP of Socio-Med, has asked non-Medicare payers their view of the AMA’s and CMS’ “relaxed rules” regarding the one-year grace period while physicians transition to full ICD-10 implementation. The following are the non-Medicare payers responses received to date:

  • Aetna: here for Aetna guidelines
  • Cigna: Click here for Cigna guidelines
  • Excellus: “There has been no official decision or discussion on this matter to date.  I suspect we will be following CMS.”
  • HealthPlus/Amerigroup: HealthPlus is evaluating CMS’s guidance for Medicare Part B and its applicability/impact to Medicaid. Consequently, we are awaiting additional guidance from CMS, as to how the agency defines “family” of codes and any guidance specific to Medicaid and Medicare Advantage.  CMS indicated additional guidance is to be forthcoming.
  • Magna Care:
  • Medicaid: We are working with CMS and are being advised that they will be issuing guidance to state Medicaid agencies sometime next week.  If you have received or seen anything from CMS it would be great if you could share.  I’ll continue to monitor from our end.
  • MVP: posts its approach and guidelines towards the ICD-10 transition online.  Here is the link.
  • Oscar: We are fairly confident that we will go by this policy for ICD-10: Claims with date of service after 10/1 must have ICD-10 or they will be  Claims received after 10/1 but with date of service before 10/1 can be in ICD-9. For your questions related to a grace period for mis-coded claims, this isn’t a decision that’s been finalized. My sense is that giving providers 365 days to correct a claim is probably too long. We’ll likely stick with our current policy which allows providers to submit an adjusted claim in X number of days after getting a claim decision. X being the number of days a provider has to submit an initial claim. So if a provider has 120 days to submit an initial claim, they’ll have 120 days after getting a claim decision from us to submit an adjusted claim if they feel they made a mistake.
  • SEIU 1199: “For outpatient claims, the 1199SEIU Benefit Funds will deny claims with dates of service on or after October 1, 2015 that is billed with ICD-9 codes.   We will not deny claims if they are submitted with a valid ICD-10 CM and will not deny claims for proper or specificity coding.  Providers can submit corrected claims within 180 days of denials/payment if needed.  For Inpatient Hospital Claims, 1199SEIU Benefit Funds will expect that hospitals apply specificity coding to assign the appropriate DRGs.  Inpatient claims are subjected to reviews to validate this.”
  • UHC: At this point UnitedHealthcare does not believe that any change in our plans is required. The CMS-AMA guidance is specific to Medicare Part B and to medical record reviews / reporting penalties. Actual claim submission (valid ICD-10 code is required for submission) and claim processing should not change (either with CMS or elsewhere). Also, CMS has not issued any additional or modified requirement to health plans regarding ICD-10 claim processing.

Subsequently, when UHC was asked: if Medicare is primary and the physician used an unspecified code within the Family of ICD-10 and Medicare extended their primary benefit, will UHC extend its secondary benefit involving the Medicare deductible and/or coinsurance?  UHC’s replied as follows:

It would still have to be a valid code—not the family code—for CMS submission.  The code submitted can be unspecified, as unspecified codes are valid codes (it should be said that UnitedHealthcare is aligned with the CMS guidance from a specificity perspective in the sense that we do not have a new edit related to ICD-10 specificity) but again it has to be a valid ICD-10 code.  Below is what CMS states about valid codes:

What is a valid ICD-10 code? (Revised 7/31/15)

Answer 3:

All claims with dates of service of October 1, 2015 or later must be submitted with a valid ICD-10 code; ICD-9 codes will no longer be accepted for these dates of service. ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity. A three-character code is to be used only if it is not further subdivided. While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, if a valid ICD-10 code from the right family (see question 5) is submitted, Medicare will process and not audit valid ICD-10 codes unless such codes fall into the circumstances described in more detail in Questions 6 & 7.

Question 5:

What is meant by a family of codes? (Revised 7/31/15)

Answer 5:

“Family of codes” is the same as the ICD-10 three-character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved. Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters. One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid.

Question 6:

Does the recent Guidance mean that no claims will be denied if they are submitted with an ICD-10 code that is not at the maximum level of specificity?

Answer 6:

In certain circumstances, a claim may be denied because the ICD-10 code is not consistent with an applicable policy, such as Local Coverage Determinations or National Coverage Determinations. (See Question 7 for more information about this). This reflects the fact that current automated claims processing edits are not being modified as a result of the guidance.

In addition, the ICD-10 code on a claim must be a valid ICD-10 code. If the submitted code is not recognized as a valid code, the claim will be rejected. The physician can resubmit the claims with a valid code.

Emblem Health Response to 7/31 Enews Article: Pulmonary Function Tests and E&M Visits on the Same Day
From Regina McNally, VP, Socio-Med
We [Emblem Health] convened a meeting (in follow-up to my forwarding your email) with representation from our Recovery Unit, Medical Directors and Legal department to ensure that all understand that CMS rescinded the MLN SE 1315 document and that it can no longer be used as grounds for recoveries. (We also confirmed that all of the requests that had been made were within the correct look back periods.) A new communication is being prepared to the providers who received the notices.

Regarding the larger issue of the use of Modifier 25, the joint understanding of the group is that it is necessary as the way for providers to let us know that a separate and distinct Evaluation and Management (E&M) service took place in addition to the diagnostic test or procedure. We agree that both events can take place on the same day and that both events can be payable, but they need to be communicated to us in a way that we can distinguish situations where the test or procedure was the sole reason for the visit from those situations where the test or procedure was performed in addition to a discrete E&M service.  According to our Medical Director, visits for “tests only” take place all the time and use of Modifier 25 is a matter of correct coding, not how medicine is practiced.

Emblem Health is planning an education campaign to let providers know that they need to distinguish stand-alone E&M services by using Modifier 25.

For Nassau and Suffolk Physicians

Adelphi University Accelerated MBA Program for Physicians
The Suffolk County Medical Society (SCMS) has formed a partnership with Adelphi University to offer its physician members (and prospective members) an opportunity to obtain an MBA degree from the Robert B. Willumstad School of Business. All classes will be held at SCMS headquarters.

All coursework is related to healthcare and will help you to run a more cost-effective practice as well as become proficient in business strategies. You’ll also gain the necessary skills to be an effective leader, critical thinker, negotiator and problem solver should you choose to be part of the decision-making process in the future of the healthcare system.

Classes will meet on Thursday evenings at SCMS, 1767 Veterans Memorial Highway in Islandia. The program will consist of 42 credits (14 courses) and is AACSB Accredited. For more information about the program, please contact Maureen Leslie, Assistant Director, at 516-237-8607 or


Doctors Digital Agency
When you understand your practice is an online business, tell us where it hurts.   Whether your website needs a simple refresh or serious surgery, our digital doctors heal what hurts. Doctors Digital Agency will improve your site’s front-end user experience and back-end functionality.  That means more patients, more phone calls, more patient time, more profitability. We use responsive design to build mobile and search-engine friendly custom websites. Leverage electrons!  Visit Email:, or call 786-529-2025. Doctors Digital Agency, Inc. Since 1996.