Tune in to this monthly online coding column, facilitated by AHIMA’s coding experts, to learn about challenging areas and documentation opportunities for ICD-10-CM/PCS.
By Elena Miller, MPH, RHIA, CCS
Although the Centers for Medicare and Medicaid Services (CMS) released a clarifying document in August of 2016 that reminded providers that flexibility related to ICD-10 codes would end on October 1, 2016, for a while there seemed to be continued flexibility even after the named deadline Well… at long last, this flexibility appears to have ended—and caught many providers off guard.
In the clarifying document, CMS reminds providers that “in ICD-10-CM, unspecified codes have acceptable, even necessary, uses” and “in some instances signs/symptoms or unspecified codes are the best choice to accurately reflect the health care encounter.” This is the tricky part—some unspecified codes are accepted while others are not.
While patterns may be detected in the denials received, there isn’t a published list of codes that will trigger a denial. There isn’t a specific patient type that is being denied. These types of denials affect inpatient and outpatient coding, including physician office coding. Providers in all settings need to code every claim to the highest level of specificity.
What should providers do to avoid unnecessary denials?
First, they should gather data.
To resolve this issue, you can’t start with the physicians. When you speak to the physicians you want to have data in hand. Simply stating that physicians need to be more specific is not enough. Start with the denials data. Is your facility receiving denials for unspecified codes? What is the volume and frequency? Is there a pattern in the codes that are being denied? Is there a pattern in the patient type? In order to take action, you need to know the answers to these questions.
Next, they should audit the records.
Determine if the use of the unspecified codes is due to missing documentation or a coding error. Don’t assume that physician documentation is the issue. Review the cases and gather the facts.
Then, they should analyze the data.
Now that you have the denials data and have audited the records, analyze the data. Identify the patient type or service line with the highest percentage of denials. What are the top ten codes denied? Is there a certain coding professional involved in more of these cases than others? Did computer-assisted coding (CAC) play a role in this? Was it a coding error, documentation issue, or both?
Finally, they should develop and execute a plan.
After you have analyzed the data, develop a plan that includes educating the coders and physicians. Speak with the facts. Rather than just giving general guidance to coding professionals, be specific. Let them know that denials have been received and which codes are most frequently being used. If you found the issue to be due to a coding error (i.e., specificity was documented in the record), let them know that as well. Make sure they understand that radiology reports can be used for greater specificity (see p. 5 of the third quarter 2014 issue of Coding Clinic for ICD-10-CM and ICD-10-PCS). Reiterate the importance of querying for this information, rather than using an unspecified code. If you find the issue to be related to documentation, identify the resources in place to communicate with the physicians. Is there a physician newsletter, medical staff committee, etc.? When possible, target the information by specialty. For example, if there is a high volume of denials in the emergency department (ED) for ovarian cysts without laterality being documented. Share that specific information with the ED physicians. If you have a clinical documentation improvement program, make sure that they are in the loop and aware of the issue.
You could also set alerts or edits in the system when particular unspecified codes are assigned. That will require you to work with your information systems and/or patient financial services departments.
As hundreds of new codes are added each year, this is something that coding departments will need to stay on top of. Conditions that are coded with an unspecified code today may have greater specificity in next year’s code set.
Elena Miller is the director of coding audit and education at a healthcare system.