Medicaid Services (CMS)
Coding Notes
Improving
Diagnosis
By Jacquie zegan, CCS, wC
Specificity in ICD-IO Coding
VALID ICD-IO-CM/PCS (ICD-IO) codes have been required for claims reporting since October 1, 2015. But ICD-IO diagnosis coding to the correct level of specificity—a more recent requirement—continues to be a problem for many in the healthcare industry. While diagnosis code specificity has always been the goal, providers were granted a reprieve in order to facilitate implementation of ICD-IO. For the first 12 months of ICD-IO use, the Centers for Medicare and Medicaid Services (CMS) promised that Medicare review contractors would not deny claims “based solely on the specificity of the ICD-IO diagnosis code as long as the physician/practitioner used a valid code from the right family.”l Commonly referred to as the “grace period,” this flexibility was intended to help providers implement the ICD-IO-CM code set and was never intended to continue on in perpetuity. In fact, this CMS-granted grace period expired on October 1, 2016.2
Unfortunately, nonspecific documentation and coding persists. This is an ongoing problem, even though the official guidelines for coding and reporting require coding to the highest degree of specificity. Third-party payers are making payment determinations based on the specificity of reported codes, and payment reform efforts are formulating policies based on coded data. The significance of overreporting unspecified diagnosis codes cannot be understated. In the short term, it will increase claim denials, and in the long term it may adversely impact emerging payment models.3•4 Calculating and monitoring unspecified diagnosis code rates is critical to successfully leverage specificity
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in the ICD-IO-CM code set.
An ICD-IO-CM code is considered unspecified if either of the terms “unspecified” or “NOS” are used in the code description. The unspecified diagnosis code rate is calculated by dividing the number of unspecified diagnosis codes by the total number of diagnosis codes assigned. Health information management (HIM) professionals should be tracking and trending unspecified diagnosis code rates across the continuum of care.5
Acceptable use of Unspecified Diagnosis Codes Unspecified diagnosis codes have acceptable, even necessary, uses. The unspecified code rate is not an error rate, but rather an indicator of the quality of clinical documentation and a qualitative measure of coder performance and coding results. Even CMS explicitly recognizes that unspecified codes are sometimes necessary. “When sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code.”6 It’s also important that coding professionals use good judgment to avoid unnecessary queries for clarification of unspecified diagnoses. The official coding guidelines provide explicit guidance for appropriate uses of unspecific diagnosis codes.7
Overuse of Unspecified Diagnosis Codes
Coding Notes
Conditions Commonly Reported with Unspecified Diagnosis Codes
Alcohol and drug use, abuse, and dependence
· Alzheimer’s disease
Arthritis
· Asthma
· Atrial fibrillation
· Atrial flutter
· Cardiomyopathy
Cerebral palsy
· Congestive heart failure (CHF) Depression
Epilepsy
· Intestinal obstruction Migraines
Neoplasms
Non-pressure ulcers
· Pneumonia
Pressure ulcers
· Respiratory failure
Sepsis
· Strokes
· Traumatic injuries
Overuse of unspecified diagnosis codes is a problematic trend. Use of unspecified ICD-IO-CM codes, ignored during the first year following implementation of the code set, is not improving. In this author’s experience, unspecified diagnosis code rates can range anywhere from 20 percent, on the low end, to over 40 percent. A diagnosis code rate over 30 percent requires investigation and appropriate corrective actions.
Widespread use of unspecified codes should be the exception, not the rule. 8 High unspecified diagnosis code rates may be due to either clinical documentation or coding practices. One strategy to ensure unspecified codes are used appropriately is to monitor unspecified code rates and address any upward trends or outliers. HIM professionals should spot check the most commonly reported unspecified codes. Review the clinical documentation on a targeted sample to confirm that the reported codes align with the degree of specificity in the health record. Examples of some conditions most commonly reported with unspecified diagnosis codes are listed in the sidebar above.
HIM professionals should identify the most commonly reported unspecified diagnosis codes in their facility and review a sample of related encounters to confirm that unspecified codes were used appropriately. When overuse of unspecified codes is identified, solutions may involve improvements in the specificity of clinical documentation or process improvement to ensure coding professionals are coding to the highest degree of specificity that is available.
Specificity in Physician Documentation
Coding specificity is a shared responsibility between the provider and the coding professional to create a clear clinical picture of the encounter. Providers have an obligation to document conditions to the full extent oftheir clinical knowledge of the patient’s health. Toward this aim, providers may need assistance—in the form of provider education or clinical queries—to recognize relevant clinical details that may impact the specificity of code assignment. Inpatient and outpatient clinical documentation improvement (CDI) efforts should address documentation specificity to leverage the details available in ICD-10-CM.
