Medicare Reminds Providers of End to ICD-10 Unspecified Codes Grace Period

The Centers for Medicare and Medicaid Services (CMS), in a clarifying document released Thursday, reminded providers that flexibilities surrounding unspecified codes will indeed end on October 1, 2016.

In the months prior to ICD-10-CM/PCS implementation, the American Medical Association (AMA) and CMS announced guidance allowing the use of unspecified codes on certain Medicare claims.

The rule stipulated that “Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family. However, a valid ICD-10 code will be required on all claims starting October 1, 2015.”

As defined by CMS and the AMA, “family of codes” is the same as the ICD-10 three-character category. “Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. For instance, category H25 (age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved.”

In the document released this week, CMS reaffirmed that this allowance will be coming to an end this coming October 1. In the document, CMS responded to questions from the provider community.

For example, in response to the question: “Is Medicare going to phase in the requirement to code to the highest level of specificity?” CMS reaffirmed that providers should already be coding to the highest level of specificity, and that “ICD-10 flexibilities were solely for the purpose of contractors performing medical review so that they would not deny claims solely for the specificity of the ICD-10 code as long as there is no evidence of fraud.”

New Resources

In addition to affirming the end of flexibilities, CMS posted a complete list of the 2016 ICD-10-CM valid codes and code titles. The codes are listed in tabular order to reflect the ICD-10-CM code book. Also available is 2017 ICD-10-CM, the updated diagnosis code set for services provided on or after October 1, 2016.

 

CMS has also posted lists for transmittals that contain code updates for National Coverage Determinations (NCDs). Local Coverage Determinations (LCDs) can be found in the Medicare Coverage Database, and are searchable in a number of ways, including the “Quick Search” function on the right-hand side of the page.

3 Comments

  1. As a neuropsychologist, I often do not have all the necessary information to specifically diagnose a client. For example, brain imaging, blood work, etc such as in a case where there is a question about differential diagnosis. Also since i am not a medical doctor i am not trained to read these tests. E.g dementia of the alzheimers type versus vascular, etc. Final diagnosis is customary deferred to the neurologist and I usually give an unspecified diagnosis. How do I proceed in this type of situation?

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    • According to the ICD-10-CM Official Guidelines for Coding and Reporting, “Codes that describe symptoms and signs, as opposed to diagnoses, are
      acceptable for reporting purposes when a related definitive diagnosis has not
      been established (confirmed) by the provider.” So you can submit diagnosis codes describing signs, symptoms or manifestations of an illness such as confusion, loss of cognitive function, behavioral disturbance, depression, etc. Once you have the lab and/or imaging results with the impression – including diagnosis – of the interpreting physician, you can add the definitive diagnosis to your patient’s medical record and report that diagnosis on your medical claims.

      Hope this helps,

      Leslie E., CPC

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  2. I recently started work in a nursing home. I have patients that are being treated for seizures. They have no idea what type or because if other comorbidties can not tell me the type of seizure that they were diagnosed with. How will I code this management if this disease with specificity.

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