Wednesday, June 15, 2022

CMS Cancels ICD-10 Changes That Erroneously Made Your Cancer Claims Unpayable

Summary

In May 2021, CMS announced it was deleting a significant number of  ICD-10 cancer codes that had historically been payable (5/5/2021 blog here).   The deletions affected the operation of NCD 90.2, which governs next-gen sequencing in cancer payments.  

I also made a video explaining how nutty this was - May 5, 2021 here.  In June 2022, CMS has given up the crazy idea.  

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In brief, in May 2021, CMS was about to delete from coverage, codes of moderate specificity (breast cancer, left breast), and would have required the highest specificity (breast cancer, left breast, upper outer quadrant.)  Often, the former but not the latter level of detail is available to labs.   By May 18, 2021, CMS put the plan on a one-year delay (blog here.)  (This May 18 blog contains a lot of detail and background about the crazy period.)  See an excellent May 2021 article at Genomeweb by Kelsy Ketchum here.   See an April 2022 letter to CMS from numerous organizations decrying the idea (here).

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In  new transmittal, June 10, 2022 (CR12124) CMS permanently cancels the plan to make the intermediate specificity codes non-payable.  (However, CMS also asserts it will continue to review issue.)  

In the interim, in spring and summer inpatient rulemaking, CMS discussed nonspecific and less-specific codes in the setting of hospital DRGs.  CMS determined in last August's inpatient rules that the intermediate codes (such as breast cancer, left breast) were fully adequate for ICD-10 coding for Medicare decisions and claims processing.

June 2022 - A Sane and Wise Final Decision


May 2021 - A Lot of Crazy


May 2021 at Genomeweb



Partly, the terminology made the arguments difficult.  CMS referred to the potentially deleted codes as "NOC" or not otherwise classified codes, which sounds reasonable to delete.   However, the codes in question were actually subsets of the smallest anatomical units - like left breast, outer half, upper quadrant, a level of anatomical detail that is meaningless for decisions like ordering a genomic test or providing a hospital admission or validating a chemotherapy order.