What exactly is an ICD-10 family?

CMS sheds light on a term that emerged from its concessions with the AMA.
By Carl Natale
09:56 AM

When the Centers for Medicare and Medicaid Services and the American Medical Association announced their agreement to make the transition smoother, a relatively new term bubbled to the top: ICD-10 "family."

Now CMS has clarified what a family is: 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

When the Centers for Medicare and Medicaid Services and the American Medical Association announced their agreement to make the transition smoother, a relatively new term bubbled to the top: ICD-10 'family'.

Now CMS has clarified what a family is: 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, will physicians will be saying how happy they are that CMS created this ICD-10 family flexibility?

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