Posted in ICD-10 & Coding

CMS clarifies what is an ICD-10 family

Carl Natale
by Carl Natale
CMS clarifies what is an ICD-10 family

The detente between the Centers for Medicare and Medicaid Services (CMS) and American Medical Association (AMA) calls for physician practices to use ICD-10 codes in the correct family in order to qualify for reimbursement.

It wasn't until this week that CMS clarified what family meant.

It's the first three characters of an ICD-10 code.

CMS uses Hodgkin's lymphoma as an example. Consider these ICD-10 codes:

  • C81.00: Nodular lymphocyte predominant Hodgkin lymphoma, unspecified site
  • C81.03: Nodular lymphocyte predominant Hodgkin lymphoma, intra-abdominal lymph nodes
  • C81.10: Nodular sclerosis classical Hodgkin lymphoma, unspecified site
  • C81.90: Hodgkin lymphoma, unspecified, unspecified site

Until Oct. 1, 2016, it will be fine to use C81.00 even if any of the other three codes could be used. But there are a couple points worth emphasizing:

  • C81.00 is correct but C81 is not. The latter will not be accepted. That will be the same among many ICD-10 families. I'm predicting this will mean many rejections for physician practices who figure "close enough for government work."
  • This family flexibility applies only to Medicare fee-for-service claims, not Medicaid or private healthcare payer claims. ICD-10 specificity will still matter.
  • National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) may require something more specific than the correct family.

A year from now, I doubt many physicians will be saying how happy they are that CMS created this ICD-10 family flexibility.

ICD-10 Experts Push Back on Physician Concerns

Sue Bowman, American Health Information Management Association (AHIMA) senior director of coding policy and compliance, and Rhonda Buckholtz, American Academy of Professional Coders (AAPC) vice president of ICD-10 training and education, address some of the concerns that physicians express about ICD-10 implementation:

  • ICD-10 terminology more closely reflects modern clinical terminology than ICD-9 terminology.
  • 46 percent of the increase in ICD-10 specificity comes from laterality.
  • Physician groups asked for greater specificity in diagnoses.
  • The increase in diagnosis codes does not make it harder to assign an ICD-10 code.
  • While it would be great to have physicians represented as a cooperating party, they already have a major role in the development of ICD-10 coding.

(HealthLeaders Media)

ICD-10 Changes for Diabetes Just the Beginning for Endocrinologists

A short list of the diseases and what endocrinologists can code:

  • Diabetes
  • Menopause
  • Goiter
  • Cushing's syndrome
  • Gout
  • Endocrine and metabolic disorders


ICD-10: Do Patients Even Need To Know?

Not unless you want to put them to sleep without anesthesia. But ICD-10 coding is something they really don't want to know about.

Except Robert Tenant,, has this suggestion for physicians to explain any delays to patients:

"Additional government regulations are requiring extra paperwork. Most patients will have no trouble understanding or sympathizing."

That's almost as funny as that "Walked into a lamppost" joke that ICD-10 opponents like to tell. (Physicians Practice)

Analyzing the Impact of the ‘‘Code-FLEX Act of 2015’’

This argument makes the case that using ICD-9 and ICD-10 codes at the same time would create more problems than it solves. (Coalition for ICD-10)