Wiki Denials for Unspecified Codes

[ABWhiteRN]

Hello,
My manager announced to the CDI specialists that CMS will not be paying for unspecified diagnosis codes. I searched to validate this statement and could not find any information. I know claims get denied for laterality frequently. But, she was stating diseases like DM2 unspecified, COPD unspecified etc. would be denied unless we query for additional specificity. Any guidance would be appreciated. Thank you.

 

[sls314]

Payers are getting more savvy about diagnosis guidelines, so many are developing policies that will deny claims that aren't assigned ICD-10-CM codes to the highest level of specificity.

However, sometimes the unspecified code IS the most specific code. Especially with something like diabetes and COPD. I can understand from a CDI perspective wanting to verify whether there were any complications that didn't get captured appropriately. Sometimes it really is diabetes without complications though.

I have not yet seen any payers policies on unspecified diagnosis codes that include things like diabetes and COPD as examples of something that will be denied.

 

[bhardwajv]

MCE edit has the list of unspecified diagnoses that will always stuck due to this edit and, if the provider does not have any specific diagnosis code then it has to be documented in the remark section of the claim that they are unable to detect the specified diagnosis for example if they are not able to document the laterality of any diagnosis they must document "Unable to DET LAT". The MAC will return the claim to you if there’s no language entered in the remarks section about the availability of information specifying. You just need to specify in the claim that the specification is not obtained or is unable to obtain.

For reference you can visit- https://www.cms.gov/files/document/mm12471-april-2022-update-java-medicare-code-editor-mce.pdf

Hope this helps