Where does it hurt…specifically?

April 24, 2017 / By Jason Mark

Over our last few posts, fellow blogger Clarissa George and I have been exploring unspecified coding. It’s been interesting to pick apart this problem. Unspecified coding isn’t new and sometimes there are very legitimate reasons for using an unspecified code. ICD-10, however, offers more specific ways of representing many conditions. Increased specificity was a major driver of the transition to ICD-10, with the promise that more specific codes would lead to a better understanding of what is happening with a patient or population of patients. Of course, if the specific codes are never used, this benefit won’t be realized. Furthermore, a lack of specificity will likely impact reimbursement. If payment is based on a fee-for-service model, then the payer drives the need for specificity. If payment is based on a population or capitated payment model, then forces within healthcare organizations will drive the need for specificity in order to optimize care delivery within bundled payment parameters. In any case, it’s beneficial to be specific when you can be, and that’s the lens our team is using when looking at unspecified coding data.

In evaluating data from more than 1,000 customer facilities, we began by reviewing some of the top conditions where unspecified coding occurs. A few of the most common are asthma, pneumonia, obesity and GI hemorrhages, which may not be surprising to coding professionals. A case of pneumonia is a good example where unspecified coding might be more common given that it may be coded before a specific organism is known. What is somewhat surprising though is that if not knowing the specific organism were the only reason for unspecified pneumonia coding, then within some reasonable amount of variance, most facilities would be in the same range. What we’re finding, however, is that this doesn’t seem to be the case. For different conditions, there can be wide-ranging results among different healthcare enterprises and facilities in terms of unspecified coding. The answer to the question of “where does it hurt” won’t be the same for every facility. Of course, there are many variables in the mix that could influence the use of unspecified codes, but at a minimum, a review of clinical documentation in weak areas seems like a solid recommendation for making sure that your facility is providing your coders with enough information to code completely.

If you’re attending the 3M Client Experience Summit this week, be sure to visit the Business Intelligence table at the Science Fair. We’ll show you the top unspecified coding conditions, including those that specifically impact DRG and HCC results. We might just be able to show you how your facility stacks up against the averages too!

Jason Mark is a business intelligence architect, Emerging Business Technology with 3M Health Information Systems.