To specify or not to specify – that is the question

Nov. 11, 2016 / By Donna Smith, RHIA, Sue Belley, RHIA

Donna: Sue, do you know how many unspecified codes there are in ICD-10-CM?

Sue: No, haven’t had time to count them!  Why do you ask?

Donna: Well, as you know, two events occurred on October 1, 2016 that impacted unspecified codes in ICD-10. First, the ICD-10 code freeze was lifted and second, the physician grace period ended. CMS had instituted the grace period to help physician practices transition to ICD-10 without fear of increased claim denials due to inaccurate codes. Oh, and by the way, there are approximately 22,500 unspecified ICD-10 diagnosis codes.

Sue: That’s a lot of codes! The lifting of the code freeze was a great thing, allowing CMS and NCHS to introduce long awaited new or revised ICD-10-CM and PCS codes. You know, there were approximately 1,943 new ICD-10-CM codes and 3,651 new ICD-10-PCS codes that became effective for claims dated October 1, 2016. It will take some time for providers and coding professionals to become familiar with all of them but they will!  What impact do you see as a result of the 22,000-plus unspecified codes?

Donna: Our clients are looking for ways to ascertain the specificity of their provider documentation as it relates to the specificity of ICD-10-CM. Even though CMS allowed flexibility in physician coding related to Part B claims during the grace period, many hospitals want to take another look at coded data  in all settings to determine the percentage of unspecified codes reported in the grace period.

Sue: You know, the flexibility allowed by the grace period was intended for auditors performing medical reviews, so they would not deny claims solely for the specificity of ICD-10-CM codes. As long as the physician used a code from the correct code family, the code was allowed. As an example, there was one code for atrial fibrillation in ICD-9, whereas in ICD-10 there are several codes for different types of atrial fibrillation, such as paroxysmal, chronic, persistent and unspecified.  During the grace period, the physician could continue to document atrial fibrillation without additional specificity and it would not be identified as a coding error. Why do you think other settings are interested in the specificity angle?

Donna: Well, I think a lot of healthcare groups and organizations did a big push to incorporate ICD-10 specificity in provider documentation starting on October 1, 2015; those who didn’t are taking this opportunity to address documentation specificity effective October 1, 2016.  Back in 2013, I ran the MedPar 2012 data to look at the extent unspecified codes were used. Thirty-two percent of all inpatient codes in the MedPar file were unspecified, with an average of 4.5 unspecified codes per claim.  I excluded claims with no unspecified codes reported.

Sue: I am really interested to see what this will look like using ICD-10 data. I hope we get some data soon now that we have one year under our belts. One more thing: When doing ICD-10 audits, I’m seeing that physicians are documenting specificity, but it’s not being identified by coders. You mentioned atrial fibrillation specificity earlier – I have found instances where physicians document chronic afib or persistent afib but coding professionals are assigning the code for unspecified afib.

Donna: I’m seeing the same thing! Like you said earlier, it’s going to take some time yet for everyone to become familiar with ICD-10. I just have to say, this is an example of how computer-assisted coding technology can help coding professionals. It can surface key documentation that sometimes goes unseen in the sea of text that coding professionals must read and process.

Sue: Well, there are many reasons why specificity is not coded and reported. Let me be clear: Many times the assignment of an unspecified code is appropriate for an encounter. The bottom line is that all involved need to work toward complete and accurate documentation, as well as coding and reporting of diagnoses and procedures in all settings.

Donna: I couldn’t agree more!  Next time, I want to tell you about my recent visit to Japan for the IFHIMA meeting and the opportunity I had to sit in on some sessions at the WHO ICD-11 conference.

Sue: I look forward to hearing about it!

Sue Belley, RHIA, Donna Smith, RHIA, are with the consulting services business of 3M Health Information Systems.

Now that the code freeze is over, what big changes are coming to ICD-10? Read about them here.