ICD-10 Claims: Medicare Submission Alternatives & Troubleshooting Common Issues

Navigating Medicare ICD-10 claim submission can be complex, especially with evolving guidelines and the need for accurate coding. This comprehensive guide provides up-to-date information on approved methods for submitting ICD-10 compliant claims to Medicare, including electronic and paper alternatives, and offers troubleshooting tips for common submission issues. Billing professionals facing difficulties with ICD-10 electronic claim submission will find solutions and updated information to ensure successful processing.

Electronic Submission via Medicare Administrative Contractor (MAC) Portals

Many Medicare Administrative Contractors (MACs) offer secure internet portals that allow providers to submit ICD-10 compliant professional claims directly. These CMS claims portals for professional claims are a valuable alternative to traditional clearinghouse submissions for certain claim types.

• Availability: While all MACs provide portals for various inquiries, a subset of these portals offer direct claims submission functionality.
• Claim Types: Provider portal internet claim submission is typically available for professional claims only and is generally not an option for institutional or supplier claims.
• Access and Registration: Information about registering for access to specific provider internet portals and their claims submission capabilities is available directly on each respective CMS Contractor’s website. We recommend checking your MAC’s official site for the most current details.

Direct Data Entry (DDE) for Institutional Claims

For providers billing institutional claims, Direct Data Entry (DDE) screens remain a permitted method for electronic submission. The Medicare DDE claims process offers a direct way to enter claim data.

• Connectivity Requirements: DDE typically requires a connectivity service provided by an external company to establish the secure connection to Medicare systems.
• Current Functionality: While the core DDE functionality remains, specific requirements and features can evolve.
• Vendor Information: Information about registering to submit claims via DDE and current lists of DDE service vendors are available on each CMS Contractor’s website. Providers should consult their MAC’s site for the most up-to-date resources.

Paper Claims: Limited Situations and ASCA Waivers

Submitting paper claims with ICD-10 codes to Medicare is reserved for truly limited situations and requires meeting specific criteria for an Administrative Simplification Compliance Act (ASCA) waiver. The ASCA generally mandates electronic claim submission, making paper claims an exception rather than a rule.

• Eligibility for Waiver: To submit paper claims, you must qualify for an ASCA waiver. Current criteria typically include:
  • Small provider exemptions (fewer than 10 full-time equivalent employees).
  • Providers who submit fewer than a specified number of claims annually.
  • Situations where electronic submission is not feasible due to system limitations, natural disaster, or other exceptional circumstances.
• More Information: For comprehensive details on current ASCA waiver requirements and eligibility for ICD-10 paper claim exceptions, visit the official CMS website at CMS ASCA Waiver Information.
• Forms and Submission: Information about submitting paper claims and ordering claim forms is available on each CMS Contractor’s website.

Troubleshooting Common ICD-10 Claim Rejections

Even with proper submission methods, claims can be rejected. Understanding common pitfalls is crucial for avoiding ICD-10 claim rejections and ensuring timely payments. Here are frequent reasons for rejections beyond just using outdated ICD-9 codes:

• Coding Specificity Errors: ICD-10-CM requires a much higher level of detail than ICD-9-CM. Claims may be rejected if codes are not specific enough to the patient’s condition or encounter (e.g., using an unspecified code when a more specific code is available).
• Invalid or Inactive Codes: Submitting codes that are no longer valid for the date of service due to annual updates (e.g., new fiscal year code changes). Always ensure you are using the most current code set.
• Incorrect Modifiers: Missing, incorrect, or inappropriate modifiers can lead to rejections. Modifiers provide additional information about a service or procedure.
• Claim Formatting Issues: Errors in how the claim form (electronic or paper) is structured, missing required fields, or incorrect data entry.
• Date of Service Mismatch: Submitting a claim with an ICD-9 code for a service performed on or after the ICD-10 effective date (though now a historical issue, it highlights the importance of correct date association).
• Lack of Medical Necessity: Although less a “rejection” and more a “denial,” claims may be questioned if the diagnosis code does not support the medical necessity of the services rendered.

Always review rejection reports carefully and consult updated CMS billing guidelines and your MAC’s specific claim submission instructions for resolution.

Information and Resources for ICD-10 Compliance

Stay current with the latest official guidance to ensure compliant ICD-10 claim submissions to Medicare. Visit the following web pages for essential information and resources:

• General ICD-10-CM/PCS Information: CMS ICD-10 Overview
• ICD-10 Fee-For-Service Provider Resources: This section includes information on claims processing, coding, unspecified ICD-10-CM codes, home health provider details, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), testing, and more. CMS Medicare Fee-For-Service Provider Resources
• General Equivalence Mappings (GEMs): For cross-referencing between ICD-9 and ICD-10. CMS ICD-10-CM and GEMs (Current Year)
• ICD-10 National Coverage Determinations (NCDs): Specific coverage policies. CMS ICD-10 NCDs

Frequently Asked Questions (FAQs)

Q: Is there still a grace period for ICD-10 coding specificity?

A: No, the grace period for coding specificity ended in 2016. Providers are expected to code to the highest level of specificity available for all claims to avoid rejections.

Q: How often are ICD-10 codes updated?

A: ICD-10-CM and ICD-10-PCS codes are typically updated annually, with new codes effective October 1st of each year. It is critical to use the most current code set for dates of service on or after the effective date.

Q: Can I use a clearinghouse for ICD-10 electronic claim submission to Medicare?

A: Yes, most providers use clearinghouses to submit electronic claims to Medicare. Clearinghouses act as intermediaries, processing claims from various providers and transmitting them to Medicare. Ensure your clearinghouse is updated with the latest ICD-10 and X12 837 claim format requirements.

Q: What should I do if my electronic ICD-10 claim is rejected?

A: First, review the rejection report or explanation of benefits (EOB) carefully to understand the exact reason for the rejection. Common reasons include coding errors, incorrect patient information, or formatting issues. Correct the error and resubmit the claim. If you need further assistance, contact your MAC or billing software vendor.

This guide serves as an essential resource for healthcare professionals navigating updated CMS billing guidelines and seeking effective solutions for ICD-10 claim submission to Medicare.