The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.
Coding with Specificity Has Its Benefits
ICD-10 Coding has garnered a great deal of attention in both this column and throughout the lectures that I have given over the last two years. One area of focus that continually emerges is the importance of specificity in selecting a code. I would estimate that I have presented on this topic to over 1,000 physicians representing most specialties. The majority of physicians want to know why it matters. Physicians argue that it does not affect the treatment of the patient. Why should they waste time trying to find just the right code when the time could be better spent caring for patients? Good question.
Continuity of care is one reason. In this electronic age sometimes the only information available to another physician providing care is a code number and its accompanying words. The diagnostic code you assign helps other physicians understand the patient’s condition and the severity of the illness. Many times, care is based on the history of care that other physicians have access to.
Medical necessity is another reason. Documentation and use of properly specific codes lends support to the level of service you are selecting for an Evaluation & Management (E&M) code. In addition, it provides support for any procedure that is provided. A properly specific code tells the WHY for a patient’s course of treatment.
All too often physicians are choosing “unspecified” in a diagnosis family. While payments are still being made, the Centers for Medicare and Medicaid Services (CMS) has indicated that effective October 1, 2016 “close-enough” coding will no longer be accepted in most instances. This will become a problem for physicians using unspecified codes after this date where other more specific codes are necessitated. It is important that you start planning now for this transition.
It is not that for every patient seen there is always a diagnosis code with the specificity that the family of codes offers. It is important to note, however, unspecified coding might be an appropriate code. A patient with unspecified pneumonia as a diagnosis is a great example of the challenges presented. You may know very little about the pneumonia and as a result treat the patient empirically and correctly code an unspecified pneumonia. There are more coding options that you can use. Is it a bronchopneumonia, lobar pneumonia, hypostatic pneumonia or some other type of pneumonia? These are the other choices in the “Unspecified organism for pneumonia” family of codes as seen below:
In other diagnostic areas where an unspecified code would be less likely to be a representation of what the physician truly knows, I see it being selected. An example is “unspecified abdominal pain” (R10.9) where the chart clearly indicates a location and whether it is a localized pain or one that is with rebound or just an abdominal tenderness. Another common “unspecified” code selected is for patients with asthma. Because of crosswalks, GEMS and often a lack of time, the quick easy code of Unspecified, asthma: J45.909 is selected. There are 18 codes in the asthma family; four sections based on severity of the asthma within each section and three codes which reflect the status of that type of asthma.
If you have a short list of common codes tacked up on the wall or printed on a sheet, you might not be coding with enough specificity. Now that the hurdles and hysteria of implementing ICD-10 have passed, it is time to continue the learning process to do it right when it comes to diagnosis documentation and code selection. As an added benefit, this will also have a positive effect on your
As I previously suggested during the conversion process, look at your top 25 utilized diagnosis codes. Ask your biller/coder to run the list again looking specifically at the past three months so you are looking at your ICD-10 codes after you had a while to use them. Look to see how many codes have the word “unspecified” in the descriptor or end in a digit of “9.” Have your biller/coder look up in a book or online (www.ICD10data.com) the words of the code and print out for you the choices associated with that illness or disease process. While there may be a large number of choices, I have found that for most physicians seeing the options will allow them to understand what code choices exist. Many times the list can be significantly reduced just by examining it and comparing the diagnoses to the types of patient’s they see. Do just two codes per week. If you have the proper data it should not take you more than 5-10 minutes to look over. With the next patient seen, you will probably remember to stage the asthma (mild intermittent; mild persistent; moderate persistent; severe persistent) and indicate its status at this appointment (with exacerbation, with status asthmaticus or uncomplicated). The time spent now will avoid hours of consternation and stress when “close-enough” will longer be accepted by CMS.