No More ICD-10 Flexibility

Coding Corner

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.

No More ICD-10 Flexibility
The Centers for Medicare and Medicaid Services (CMS) recently released updated “Frequently Asked Questions” regarding the one-year timeline that allowed for “flexibility” in using ICD-10 codes.  It provides valuable insight into what CMS will do differently as of October 1, 2016.  The important information that I see is as follows:

  • There will be no further extension allowing for ICD-10 coding flexibility;
  • There will be no additional flexibility guidance;
  • There still will be instances where unspecified codes are acceptable;
  • Beginning October 1, 2016, all CMS review contractors are able to use coding specificity as the reason in an audit for denial of a reviewed claim; and
  • Providers should code claims to the degree of specificity supported by the encounter and the medical documentation

Claims previously submitted with unspecified ICD-10 diagnosis codes were not denied.  That will change; however, it is possible that an unspecified code will remain the most specific and appropriate code to use.  An example of this is a patient seen in the office with a diagnosis of bacterial pneumonia, unspecified (J15.9).  The provider has made a diagnosis. They empirically treat the patient and do not feel the need to obtain a culture to determine what type of bacterial pneumonia the patient has.   So, the unspecified code is the correct choice and the claim should be paid.  This should not change after October 1, 2016.
A different example would be a chart stating that the patient has hypertensive heart disease with heart failure (which would be coded as I11.0), but the diagnosis shown in the Assessment and Plan is listed only as “hypertension” and coded as I10.   In this example, the chart documentation has more specific information (hypertension with heart failure) than was coded in selecting I10 (essential hypertension). During an audit, the lack of alignment of documentation and diagnosis will be discovered and the claim would be denied and payment recovered by CMS.
This requirement of specificity in coding is for all encounters billed by physicians to CMS (or most payers) in any location.  Be sure when completing your note for a patient, your final diagnosis for the visit is as detailed as possible.  It may take an extra second of your time to be sure your diagnosis is at the highest level of specificity, but it will save you time and potential negative financial consequences when your documentation is audited.  Additional information is available at

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