CMS issued a recent alert (click here) warning Responsible Reporting Entities (RREs) to accurately report ORM and ICD-9/ICD 10 codes. CMS intends that effective January 1, 2016 to use this information from Section 111 data to coordinate benefits for Medicare beneficiaries. This means that injured workers or other no-fault claimants will have Medicare benefits stopped during the period of the RREs Ongoing Responsibility for Medicals for ICD-9/ICD-10 codes related to the workers’ comp or no-fault injury. Therefore, care must be taken when ICD codes are entered into claim systems as this information will set the parameters for what Medicare will pay for going forward.

Franco Signor Commentary: RREs will see a gradual increase of calls from injured workers and no-fault claimants after January 1, 2016. This is due to the fact that Section 111 data is reported by each RRE during a specific quarter. This will be the first quarter that CMS will be receiving the more accurate ICD-10 codes for claims with a loss date on or after 10/1/2015. It is our expectation that CMS has waited to coordinate benefits until 1/1/2016, due to the fact that ICD-10 coding will provide a more accurate description of the injur(ies) associated with the workers’ compensation or no-fault claim(s). Our expectation is that CMS will be very aggressive to coordinate benefits on those claims with ICD-10 codes.

It is unclear if CMS will rely solely on the ICD-10 codes or apply a filter to grab other ICD-10 codes that are around the cluster of treatment related to the reported date of loss. As most RREs typically report only the obvious injury codes, CMS may data mine it’s ReMAS database (more information on ReMAS can be found here) to find related codes. Increased accuracy in reporting by RREs of ICD-10 codes related to an injury may reduce CMS errors in using the filtering process.

One thing for certain is that Medicare beneficiaries who have worker’s compensation or no-fault claims will gradually experience this new CMS coordination policy and claims processors should brace for increased claimant inquiries. Directing claimants to the BCRC or CRC to resolve this benefit issue will not work, as the RRE’s Section 111 data will control and any payments made by Medicare will result in a conditional payment claim. The best approach is for RREs to accurately report ICD-10 codes (up to 21 codes will be accepted) and regularly update them as injuries or codes change.

Roy A. Franco 
Franco Signor
Chief Client Officer

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