Tag Archives: ICD-10

CMS Announces Switch on NGHP Conditional Payment Recovery from BCRC to CRC and Use of ICD-9 and ICD-10 to Determine Payment of Medical Bills

Article by Rafael Gonzalez, Esq. Vice President, Strategic Solutions HELIOS Settlement Solutions

Article by
Rafael Gonzalez, Esq.
Vice President, Strategic Solutions
HELIOS Settlement Solutions

On July 1, 2015, CMS published an announcement on its upcoming transition of Non-Group Health Plan recovery workload from the Benefits Coordination & Recovery Center to the Commercial Repayment Center.

As part of the continuing efforts to improve the Coordination of Benefits & Recovery (COB&R) program and claims payment accuracy in Medicare Secondary Payer (MSP) situations, the Centers for Medicare & Medicaid Services (CMS) will be transitioning a portion of the Non-Group Health Plan (NGHP) recovery workload from the Benefits Coordination & Recovery Center (BCRC) to its Commercial Repayment Center (CRC). CMS will also be working closely with its claims processing contractors to make sure that Medicare pays correctly in the MSP situations described below.

Effective October 2015, the CRC will assume responsibility for the recovery of conditional payments where CMS is pursuing recovery directly from a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation (WC) entity as the identified debtor.

The following should be noted regarding the planned workload transition:

  • The transition only includes those cases where CMS is pursuing recovery from the liability insurer, no-fault insurer or WC entity directly.
  • Beneficiaries and their attorneys will continue to work with the BCRC where CMS is pursuing recovery from the beneficiary.
  • Webinars and town halls will be scheduled in the coming months to provide additional information.

For readers who are not familiar with Medicare’s Commercial Recovery Center, the CRC currently handles Group Health Plans (GHP) recoveries. Therefore, based on this announcement, it is anticipated that all NGHP recovery related activities, where CMS is pursuing recovery from the liability insurer, no-fault insurer or WC entity directly, including refund checks, correspondence, and telephone inquiries will be handled by the CRC. This may include recovery demand letters, repayment of debt, administrative appeals request, and notice of intent to refer debt to the Department of Treasury letters.

We do not yet know whether there will be any changes to the current NGHP recovery process as a result of the CRC assuming responsibility for recovery of such conditional payments. As always, Helios Settlement Solutions will continue to track such changes and will continue to inform as to any procedural and administrative effects resulting from same.

The announcement also indicates that “effective January 1, 2016, CMS will add an additional limitation to Medicare claims payments where insurers or workers’ compensation entities have reported to CMS that they have Ongoing Responsibility for Medicals (ORM).”

The announcement explains that “in situations where an insurer or workers’ compensation entity has reported to CMS that it has ongoing responsibility for medicals (ORM) for specific care, CMS’ claims processing contractors will use the information provided by the insurer or workers’ compensation entity to determine whether Medicare is able to make payment for those claims.” As a result, “insurers and workers’ compensation entities that notify Medicare that they have ORM are strongly encouraged to report accurate ICD-9 or ICD-10 codes as Medicare’s claims processing contractors will use this information to pay accordingly.”

Although we have all known for quite some time that information provided to CMS via the Mandatory Insurer Reporting (MIR) process would be used to determine whether Medicare is the primary or secondary payer of any bill received by Medicare on any given claim, this announcement makes it clear that as of January 1, 2016, CMS will in fact start using the ICD-9 or ICD-10 reported by employer/carrier/TPA/agent to determine whether Medicare should pay or deny such bills.

As a result, with ICD-10 requirements starting October 1, 2015, now more than ever, every employer, carrier, third party administrator, or agent reporting such information to CMS needs to make sure that the ICD-9 or ICD-10 codes provided to CMS are accurate and comply with the applicable guidelines. Not doing so may result in Medicare paying for items it should not have paid for, or denying payments on items it should have paid. Either way, these errors and mistakes may become the source of potential private causes of action under the MSP, or liability and professional malpractice claims away from the MSP.

As an industry leader delivering what I believe to be the best platform for MIR compliance through MedicareConnect℠, Helios can assist RREs, TPAs and insurers ensure the proper use of ICD coding throughout all areas of MSP compliance. Coding the claim correctly means the best possible outcome once the claim is reported to CMS. As a result, Helios recommends the reporting process itself should be reliable and allow for sufficient guidance to ensure the claim is accepted by CMS without the issues of mixed coding or utilization of codes not acceptable by CMS for NGHP Section 111, including where plan type may prevent usage of specific codes. To learn more about Helios’ MedicareConnect℠, please contact us at 888.672.7674, or contactus@helioscomp.com, or www.helioscomp.com/settlement-solutions/medicareconnect-mir.

CMS Educates the Public about ICD-10 through Instructional Videos; ICD-10 Set to go Live October 1, 2015

frankCMS has introduced two new videos on ICD-10. The videos can be found here. The videos are exceptional in explaining ICD-10 basic concepts and drives home why ICD-10 will help better communicate diagnoses in the healthcare industry than previously was available with ICD-9.

ICD-10 will not only be required by providers when billing for medical services, but additionally RREs will also have to utilize ICD-10 when reporting claims through MMSEA Section 111 to CMS. As a reminder, CMS last year issued a memorandum outlining the ICD-10 process for RREs which is set to begin October 1, 2015 (link can be found here).

Are you ready for ICD-10 implementation? MedicareConnect, our industry leading Mandatory Insurer Reporting (MIR) solution, is ahead of the curve for the October 1, 2015 ICD-10 implementation date and completely ready for the transition. Helios provides a free lookup tool which converts ICD-9 to ICD- 10 and can be found here (users can simply enter their e-mail address for access).

For more information on the ICD-10 transition or MedicareConnect, please contact Frank Fairchok, MedicareConnect Program Manager, at Frank.Fairchok@helioscomp.com.

CMS Announces ICD-10 Delay for MMSEA Section 111 Reporting

We previously notified our subscribers in a blog that Congress passed a Bill (HR 4302) which included a provision that delayed the implementation and transition to ICD-10 coding until October 1, 2015.

As expected, CMS has now released an alert which provides that RREs are to postpone reporting ICD-10 codes until October 1, 2015. The alert can be found here.

For any questions, please contact JustRegister@PMSIonline.com.

CMS Releases NGHP Alert on ICD-10-CM Coding

CMS has released a technical alert for NGHPs dated March 25, 2014 that pertains to the reporting of liability insurance, no-fault insurance, and worker’s compensation claims. This alert provides new and clarified guidance around the usage of ICD-10-CM codes as follows:

  • New Excluded ICD-10-CM Diagnosis Codes
    • ICD-10-CM “Z” diagnosis codes are considered invalid for Section
      111 reporting and must be excluded from use in claim reports.
    • CMS has determined that these ICD-10-CM “Z” codes do not provide enough information related to the cause and nature of an illness, incident, or injury to be adequate for Section 111 reporting usage.
    • ICD-10-CM “Z” codes will not be accepted in either Field 15 (Alleged Cause of Injury, Incident or Illness) or in Fields 18 through 36 (ICD Diagnosis slots 1 through 19) of the Claim Input File Detail Record.
    • The “Z” codes are not listed separately on the exclusion list in the NGHP User Guide, Appendix I.
  • Clarification On The Use of V, W, X and Y Codes
    • ICD-10_CM diagnosis codes beginning with the letters “V,” “W,” “X,” or “Y” may only be used in Field 15, the Alleged Cause of Injury, Incident, or Illness, as long as the code does not appear on the excluded diagnosis code list in the NGHP User Guide – Appendix I.
    • These codes are considered invalid for usage in Fields 18 through 36(ICD Diagnosis slots 1 through 19).

This new alert can be found at the following address: