House Passes Measure to Delay ICD-10 Transition

STOP THE PRESSES… Possible Delay in ICD-10 Transition

By voice vote on Thursday, March 27, the House approved another temporary (one-year) fix to prevent steep cuts in Medicare’s physician reimbursement scheduled to take effect March 31. It now moves to the Senate which is expected to take action within the next few days. The draft legislation does not address the problems with the Workers’ Compensation Medicare Set-Aside approval process. However, there is language that speaks to a possible delay in the ICD-9 to ICD-10 transition, which could impact the MMSEA Section 111 mandate for reporting ICD-10s.  Other key inclusions include a two year delay in the provision overturning two U.S. Supreme Court decisions that prevented state Medicaid agencies from recovering 100 percent of their medical payments from the proceeds of liability settlements involving Medicaid beneficiaries and at least a one-year delay Medicaid mandated that providers move from ICD-9 coding to much more complex ICD-10 coding which will have a significant impact on insurers data reporting and bill payment functions.

CMS Issued Alert

It was only on this past Tuesday, March 25, 2014, that the Centers for Medicare and Medicaid Services (CMS) published an Alert regarding ICD-10 Diagnosis Codes, which further tightens the list of acceptable codes for Mandatory Insurer Reporting (MIR) purposes.

ICD-10 codes beginning with the letter “Z” are related to factors influencing health status and contact with health services, and are considered invalid for MIR.  This includes all 19 Diagnosis Code fields as well as the Alleged Cause of Injury, Incident or Illness field.

MIR ICD-9 Codes for Free

The Alert also clarifies the use of ICD-10 codes beginning with the letters V, W, X and Y.  These codes are related to external causes of morbidity and mortality, and may only be populated in the Alleged Cause of Injury, Incident or Illness field, as long as they are not on the list of excluded codes in the NGHP User Guide.  Additionally, these V, W, X and Y codes are invalid for use in the 19 ICD-10 Diagnosis Code fields.

Gould and Lamb has applied the appropriate quality audits, alerts, and metrics to ensure our customers are compliant with the transition.  Should you have any questions regarding this or any other topic related to MIR, please contact your MMSEA Compliance Manager or our Reporting Services Department at or 866-672-3453 ext. 1122.

Additional details on the bill can be found here.

New Fixed Percentage Option for Conditional Payment Resolution

Christie Luke Vice President Operations

As expected, on November 7th, the Centers for Medicare & Medicaid Services (CMS) implemented a new fixed percentage option for Conditional Payment Resolution (CPR).  The new fixed percentage option makes the process simpler and faster.  Any beneficiary who meets the criteria below can resolve Medicare’s Conditional Payment recovery claim by paying a flat 25% of his/her total liability insurance settlement.

Required Criteria

In order to qualify, all of the following criteria must be met:

  1. The liability insurance settlement must be for a physical trauma based injury, and
  2. The total liability settlement, judgment, award, or other payment is $5,000 or less, and
  3. The beneficiary elects the option within the required time frame
  4. Medicare has not issued a demand letter or other request for reimbursement related to the incident, and
  5. The beneficiary has not received and does not expect to receive any other settlements, judgments, awards, or other payments related to the incident.

When to Exercise the Option

There are some guidelines as to when to exercise the option:

  1. The request must be submitted before or at the time the settlement documentation is submitted.
  2. If a Conditional Payment Notice (CPN) has been issued, the request must be on or before the CPN response is due (30 days from the date of the CPN).

In order to elect this option, documentation must be completed by the beneficiary or his representative, and mailed to the MSPRC.  Requests are processed in the order received.  So, it is imperative that when selecting this alternative the request is submitted timely.

If the request is denied, a formal letter will be provided with an explanation, and a regular Demand will be sent under separate cover.  If approved, the beneficiary will receive a bill for the amount specified (i.e. 25% of the settlement).

Wait & See

As indicated in our previous Industry News Bulletin of October 26th, the new procedure is a seemingly good way to speed up the process on ‘smaller’ Liability settlements.  However just how many claims will meet this criteria is yet to be determined.

About the Author: Christie Britt is the Vice President of Operations overseeing the extensive operations of Gould & Lamb.   She has vast knowledge of Medicare Set Asides and Post-Settlement Administration from an insurance claims perspective. Christie is MSCC certified and has her Green Belt Certification in Six Sigma.  She is also a member of the National Association of Medicare Set Aside Professionals (NAMSAP) and the Workers’ Compensation Claims Professionals (WCCP).

Gould & Lamb is a global leader of MSA/MSP Compliance Services in the country, serving domestic and international insurance companies, third-party administrators and self-insured entities.