American Society of Plastic Surgeons
For Consumers

FAQ: ICD-9-CM to ICD-10-CM Grace Period

The ASPS Quality and Health Policy Department has provided the answers below to frequently asked questions regarding the One Year Grace Period in the transition from ICD-9 to ICD-10.

  1. Can I report ICD-9-CM codes during the grace period?
    • For services provided after September 30th, Medicare will no longer accept ICD-9-CM codes.
  2. What is the grace period?
    • The new regulation stipulates that claims will not be rejected for payment for the simple reason that the ICD-10 code submitted is not specific enough.
    • Most codes within a category are clinically related but capture specific information on the type of condition being treated. Examples of valid codes for "other disorders of the breast" includes:
      • N64.0 Fissure and fistula of nipple
      • N64.1 Fat Necrosis of breast
      • N64.2 Atrophy of breast
      • N64.4 Mastodynia
    • If a provider sees a patient for fat necrosis of the breast, but inadvertently submits the ICD-10 code for fissure and fistula, the claim will not be denied by Medicare because both codes are in the same "category" of ICD-10 codes. The only exception to this would be if there is a local coverage decision policy that has strict limits on the ICD-10 codes that are approved for payment. In those cases, a claim will be denied if the correct code is not submitted. 
  3. Can I report both ICD-9 and ICD-10 codes after October 1?
    • All claims submitted with a date of service after September 30, must be coded in ICD-10-CM.
  4. Is ICD-10 being implemented on October 1, 2015?
    • All claims submitted with a date of service after September 30, must be coded in ICD-10-CM.
  5. Will the lack of specificity impact PQRS & other quality reporting programs?
    • Those physicians who participate in CMS quality programs such as the Physician Quality Reporting System (PQRS), the value-based payment modifier initiative and/or meaningful use of electronic health records will not be penalized during the 2015 reporting year for failure to select a specific code, as long as they have selected one from an appropriate family of codes. Moreover, practices will not be penalized if CMS encounters trouble in accurately calculating quality scores.
  6. What are my options if my practice management system hasn't been updated to allow reporting of ICD-10 codes?
    • If you cannot submit ICD-10 claims electronically, Medicare offers several options:
      • Obtain free billing software that can be downloaded at any time from every Medicare Administrative Contractor (MAC).
      • Look for Part B claims submission functionality located directly on many of the MAC's provider internet portal.
      • Consider submitting paper claims, if the Administrative Simplification Compliance Act waiver provisions are met. If you take this route, be sure to allot time for you or your staff to prepare and complete training on free billing software or portals before the compliance date.

Each of these options requires that the provider be able to code in ICD-10.

  1. Will CMS audit diagnoses on claims in CY 2016?
    • Medicare claims will not be audited based on the specificity of the diagnosis codes used as long as they are from an appropriate family of codes.
  2. Where can I find a list of ICD-10 codes?