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Feb 27

Don’t rely on the Unspecified in ICD-10 CM

  • February 27, 2014
  • Patti M
  • ICD-10, Revenue Cycle

For years, we have been consulting providers and teaching “if it wasn’t documented; it wasn’t done”.  ICD-10-CM confirms that not only will you need to document what was done, you need to code for it. The use of  “unspecified” codes has been a common topic of discussion in the industry, even prior to ICD-10-CM.  Some providers became accustomed to “adding a 0” in order to accommodate the fifth digit expansion in ICD-9-CM. This created a growth in the practice of utilizing these “unspecified” diagnosis codes.

 Providers frequently ask “are we going to have payment changes on October 1, 2014 with ICD-10?”  My answer is “Yes” and “No”. Initially, we may not be paid directly on ICD-10-CM codes, but the ramifications of incorrectly utilizing the new codes are enormous.

Some payers will look for reasons to deny the medical necessity of services that providers render and unspecified code usage certainly seem to be the target of additional pre-review questionnaires, denials and even third-party audits. This delay in payment can have a significant impact on your cash flow.

Provider claims can be a review target when you report a Level 4 or 5-  E/M code with an unspecified ICD-9-CM diagnosis code. Payers may presume that this “vague” and “unspecified” diagnosis may not support the medical necessity of the higher levels of  E/M services provided. The correlation can also be presumed that if the diagnosis is unspecified, then perhaps the E/M level might not be properly documented.

It will become even more important to avoid unspecified codes once ICD-10-CM takes place on October 1, 2014.  ICD-10-CM codes are generally more specific in nature and providers need to take advantage of this level of specificity to improve the process of getting paid and to tell the “story” of the encounter more effectively.

The Centers for Medicare and Medicaid Services (CMS) has provided clarification on the use of “unspecified” codes when using ICD-10.  They acknowledge that both ICD-9-CM and ICD-10-CM, “unspecified” codes have acceptable, even necessary, uses.  “While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the health care encounter.  Each health care encounter should be coded to the level of certainty known for that encounter.”

 Many EHR systems plan to use the GEM’s to crosswalk the existing diagnosis codes to the new ICD-10-CM codes. Although this plan sounds good in theory, the level of detail provided in the ICD-10 codes does not provide a direct match in many cases.  The more specific you are currently in ICD-9-CM, the better chance there is to map to an ICD-10-CM.

 An important step in your ICD-10-CM implementation plan is ensuring clinical documentation is sufficient for the new code set.

  • Identify your pattern of unspecified and other specified code use. 
    • In ICD-9, unspecified and other specified can be identified by looking at the 4th or 5th digit of the diagnosis code
      • Codes titled other or other specified are usually a code with a 4th digit of 8 or 5th digit of 9
      • Codes titled unspecified are usually a code with a 4th digit of 9 or 5th digit of 0
  • Identify providers that have a greater unspecified and other specified code usage
  • Target education and review to those providers to use a more specified code in ICD-9-CM, if available prior to the ICD-10-CM implementation.
  • Begin looking at current documentation and “dual code” for the services in ICD-10-CM

The complete, accurate, and detailed documentation of the encounter will be necessary for assigning appropriate ICD-10-CM codes just as it is in ICD-9-CM. Yes, there are “unspecified” codes, but some payers have stated that they are not going to reimburse claims with these codes under ICD-10-CM. Also, government and third-party payers are going to assign severity and risk scores based on the diagnosis codes billed, and these scores will help you justify higher level codes and better reimbursement in the future.  Start now to assign the accurate ICD-9-CM code for the documentation that you provide and you can make a step for easier transition on October 1, 2014. 

 

 

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