ICD-10: What’s a Family, Anyway?

When the Centers for Medicare & Medicaid Services (CMS) announced the 12-month grace period for full compliance into ICD-10 back on July 6 (http://duxware.com/putting-your-dux-in-a-row/95-icd-10-grace-period), there was one significant condition - all claims must be filed within the “right family” of codes to be considered eligible.

What wasn’t clear about that condition was the definition of a “family”. In fact, the lack of a definition of “family” caused a great deal of confusion.

“Is it a category of codes, such as S00, superficial injury of head? That could be interesting,” wrote Michelle Leppert of HealthLeaders Media (http://healthleadersmedia.com/content/TEC-318822/ICD10-Whos-in-the-Family-of-Codes) on July 23. “S00 has nine subcategories of codes, each with their own subcategories. Or does CMS mean those subcategories, say S00.4, superficial injury of ear? Again, S00.4 includes eight subcategories with their own subcategories.”

So, while the grace period was seen as a victory by many, the confusion around the terms of the period actually increased.

That, however, has changed.

CMS has issued a new version of its Frequently Asked Questions regarding ICD-10, where it finally clarifies what a family is - the first three characters of the code.

That seems to be pretty straightforward. The example that CMS references, however, is quick to identify one very important thing.

“An example is C81 (Hodgkin’s lymphoma) – which by itself is not a valid code,” the document reads (https://www.cms.gov/Medicare/Coding/ICD10/Clarifying-Questions-and-Answers-Related-to-the-July-6-2015-CMS-AMA-Joint-Announcement.pdf). “One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid.”

OK … so, what, then is a valid code? In most cases, five characters will be required.

“C81.00 is correct but C81 is not. The latter will not be accepted,” writes Carl Natale, the editor of the ICD10Watch blog (http://www.healthcareitnews.com/blog/what-exactly-icd-10-family). “That will be the same among many ICD-10 families.”

While the clarification is helpful, Natale believes that there will still be significant problems.

“I'm predicting this will mean many rejections for physician practices who figure ‘close enough for government work,’” he writes. 

There’s also another stipulation to the grace period that may be falling under the radar, Natale adds.

“This family flexibility applies only to Medicare fee-for-service claims, not Medicaid or private healthcare payer claims,” he writes. “ICD-10 specificity will still matter.”

So, while the grace period seemed like a bit of a reprieve, it’s only guaranteed to apply for Medicare claims. While some private healthcare payers may also honor the grace period, be sure to contact each private payer to see what their coding standards will be and whether or not they plan on honoring the grace period to make sure you are in compliance.

And remember - a family requires at least five characters, not just three.