News: CMS clarifies "family of codes"

CMS has offered some clarity on what it considers to be a “family of codes” in ICD-10-CM.

On July 6, 2015, CMS made a deal with the American Medical Association (AMA) to get them on board with ICD-10-CM/PCS implementation. As part of this deal, the two organizations made an announcement that, for the first year of ICD-10-CM/PCS use, CMS will not deny or audit claims based on the specificity of diagnosis codes, as long as the codes on these claims are from the correct “family of codes.”

At the time, CMS did not specify what “family of codes” meant, which caused confusion and had some in the industry claiming that CMS would pay for “wrong” codes.

So CMS clarified last week releasing “Clarifying Questions and Answers Related to the July 6, 2015 CMS/AMAJoint Announcement and Guidance Regarding ICD-10 Flexibilities.” The document includes 13 questions, covering topics from claim rejections to code specificity. Three questions clarified the term “family of codes” explaining that a family is any code within 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.

Take category H25 (age-related cataract): this category, according to CMS, is a family. The family contains a number of specific codes that capture information on the type of cataracts, as well as information on the eye involved.

If a coder were to report H25.9 (Unspecified age-related cataract) when the patient really suffered H25.031 (Anterior subcapsular polar age-related cataract, right eye), CMS would not audit or deny this claim because a valid code was reported within the correct family.

CDI specialists must note that CMS never said it wouldn’t deny or audit claims for medical necessity. Additionally, this “deal” with the AMA only pertains to private physician practice not hospital claims.This means CDI needs to work especially hard to make sure the documentation is as specific as possible, and clearly supports why the patient required the treatment they received. With specific, detailed documentation, coders will be able to report the most specific code.

Editor’s Note: This article was based on “Meet the family” originally published in ICD-10 Trainer. To read the full CMS Q&A, click here.