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ICD-10 Intelligence

Devils and Details

Why unspecified codes matter and how to prepare for impending denials.

Q: Our hospital, which owns 20 physician practices, is launching a system-wide effort to reduce the volume of unspecified codes. We're hoping this project will help our physician practices prepare for the conclusion of the ICD-10 grace period on October 1, 2016.

What are the most prevalent unspecified codes you've seen in the industry? Are there any coder guidelines for effective physician queries when "unspecified" is the only option? And finally, how can we work with our physician practices to help them report greater specificity?

A: I'm glad to hear you are initiating this effort to thwart unspecified codes. According to the FY 2016 ICD-10-CM Official Guidelines for Coding and Reporting, unspecified codes are appropriate only in certain circumstances:

When sufficient clinical information isn't known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate "unspecified" code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient's condition at the time of that particular encounter.

Still, it's in every organization's best interest to query for more specific information. Although retrospective payer audits continue to focus on ICD-9 claims, these audits will eventually phase out, and auditors will only scrutinize ICD-10 claims. We predict payers will only accept unspecified codes in limited circumstances, choosing instead to promote the rich detail inherent in ICD-10. Here are several tips to consider for your coding team and your physician practices.

Three Steps for Your Coding Team

Coders are the first line of defense against unspecified codes. Here are three ways to get ahead of the "unspecified" challenge within your coding department:

1. Develop a "target" list for unspecified codes. If your hospital is struggling with unspecified codes, it is quite likely that your owned physician practices are also plagued with this problem. Address the importance of specificity now-before the grace period ends.

Begin with your most common unspecified culprits. At HRS, we've seen an increase in unspecified codes related to the following three diagnoses:

  • Cerebral infarction-Coders should identify the specific site of the infarction if documented
  • Myocardial infarction-Coders should identify the specific artery if documented
  • Fractures-Coders should identify laterality if documented. 

2. Include query criteria from the AHIMA query practice brief published in February 2013. In particular, the brief states that queries are appropriate when documentation:

  • Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
  • Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis
  • Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure
  • Provides a diagnosis without underlying clinical validation
  • Is unclear for present on admission indicator assignment

At HRS, we sometimes see coders incorrectly default to an unspecified code when provider documentation is conflicting. For example, an ER physician documents left broken tibia and the orthopedic specialist documents right broken tibia. Instead, coders should query for clarification-not assume that the clinical details are unknown.

Also, identify common chronic conditions that are controlled with medication (e.g., hypothyroidism, hyperlipidemia, or constipation) and clarify query policies accordingly. Due to the resource intensity of the query process, some organizations may default to an unspecified code for these chronic conditions.

3. Encourage coders to go the extra mile. It may be easier-and more efficient-to default to an unspecified code; however, data integrity should always be top priority. Reiterate the importance of reviewing the operative and radiology reports for more information. According to Coding Clinic First Quarter 2013: Page 28, coders can use the radiology report to glean additional information about laterality, anatomical specificity, and more. Once your coders are more aware of the unspecified issue, turn your attention to physician practices.

Four Strategies for Physician Practices

At the end of the ICD-10 grace period, physician practice bulk denials may become an ugly reality. That's because once auditors are allowed to deny for reasons beyond medical necessity, physicians won't have the luxury of simply reporting a code from the correct "family of codes." Instead, they'll be held to the same standards as all other providers-they must report the most specific code possible.

When working with owned or affiliated physician practices, consider these four tips for documentation within the hospital record and physician practice encounter notes:

1. Take a targeted approach. Identify each practice's top 5-10 diagnoses. How many are typically reported as unspecified? Are these codes truly unspecified due to a lack of documentation, or are coders simply defaulting to unspecified codes in error? Provide education to break old, established physician documentation habits for these diagnoses.

2. Educate physicians on the relationship between unspecified codes and public reporting. Physicians recognize and respect the importance of public quality reporting such as HealthGrades and Physician Compare. Work with your Quality and CDI departments to link unspecified codes to poor performance on quality measures and patient safety indicators-then inform your medical staff accordingly. After education is conducted, require coders to query for these diagnoses when greater specificity is required but not documented.

3. Audit cloned documentation. Documentation that's copied and pasted from an old problem list in the EMR can wreak havoc on specificity-especially when those conditions were never specified in the past. Without oversight, these unspecified diagnoses could be occurring. Encourage physicians to use this EMR function with caution and to validate and specify each diagnosis brought forward to the current encounter.

4. Update the superbill. With some specialties, it may be possible to add more specific diagnoses to the superbill so physicians don't automatically choose the unspecified option during office visits. While the effectiveness of this strategy depends on the specialty, it is certainly an important step in reducing the volume of unspecified codes.

Exception Versus Rule

Though they remain an option in ICD-10, unspecified codes should be the exception rather than the rule. Unspecified codes provide minimal insight into a patient's condition and have a detrimental effect on future MS-DRG rates and CC/MCC classifications.

Consider the life-threatening diagnosis of respiratory failure. Although this diagnosis is currently a MCC, many providers continue to ignore the fact that we must specify acute, chronic, or acute on chronic. This was problematic in ICD-9, and continues to be a challenge in ICD-10. However, without this specificity, we run the risk of seeing this MCC reduced to a CC or even a non-CC/MCC condition.

Take the time now to examine your organization's volume and type of unspecified codes. Then extend this effort beyond your walls to include physician practices. Use the next six months to your advantage. You'll be thankful that you did.

Kimberly Carr  is the director of clinical documentation for HRS, where she oversees the auditing consulting services and provides education and training to the remote coders and auditors. Before joining HRS, Carr worked as a consultant for multiple major consulting practices as well as on the provider side, as a Clinical Documentation Improvement Manager and HIM Coding Educator for a large health system. She  has also worked for several community hospitals in Tennessee.

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