Think Twice Before Using Unspecified Codes
ICD-10 is so specific that reporting unspecified codes will raise documentation red flags.
By Shelly Cronin, CPC, CPMA, CPPM, CPC-I, CANPC, CGIC, CGSC
Diagnosis coding is traditionally viewed as unessential to claims reimbursement; however, with ICD-10 that may change. Payers are going to great lengths to beef up their policies and to map their covered ICD-9-CM codes to all pertinent ICD-10-CM codes. When the ICD-10 code set is implemented in 2014, payers will be looking for claims to contain highly specific codes to support the medical necessity of procedures and services performed by clinicians. Getting paid for “unspecified” diagnoses may be as difficult as getting paid for “unlisted” procedure CPT® codes; and overuse of unspecified ICD-10 codes may subject your provider to audits.
This is because the ICD-10 code set contains enough specificity and granularity that using an unspecified code should be a last resort. Think of unspecified ICD-10 codes just as you would unlisted procedure codes in CPT®: You should use an unlisted code ONLY if a specific code for the procedure does not exist. Learning to avoid unspecified codes now will help you with the transition to ICD-10.
Review Unspecified Code Use
Unspecified codes exist for a few reasons—some good and some not so good. A coder may resort to using unspecified codes when:
- Documentation is insufficient.
- Documentation isn’t accessible at the time of reporting.
- The billing sheet has an overabundance of unspecified codes.
- He or she has often-used codes committed to memory.
For example, if a patient is seen in the office for diabetic retinopathy, the provider’s documentation must answer the fol-lowing questions for accurate code selection to take place:
- Does the patient have type 1 or 2 diabetes?
- Does the patient have proliferative or non-proliferative retinopathy?
- What severity is it: mild, moderate, or severe?
- Does the patient have macular edema?
Without documentation of macular edema, even reporting an unspecified code for this case would be difficult. This is because the code descriptors for type 2 diabetic retinopathy specify whether macular edema is present:
E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema
Assume the provider reports the visit as a level 4 or 5, and doesn’t document enough to report anything other than diabetic retinopathy. The service could not be submitted, simply because an ICD-10-CM code could not be selected. Even the most unspecified code in the section, E11.8 Type 2 diabetes mellitus with unspecified complications, is inappropriate because the complication for this patient is known.
The Role of E Codes
Another concern when it comes to the ICD-10-CM transition is the external cause codes. The former E codes in ICD-9-CM are rarely used now. But almost all emergency departments (EDs) should report these codes because they are the first line of reporting for trauma and abuse, along with other injury cases.
Payers will look for the external cause and place of occurrence codes to provide detail into what the patient was doing when the injury happened. Where was the patient? Did the accident happen on the job? The external cause codes will quickly provide payers with details to indicate if the claim should go to the patient’s workers’ compensation payer, or that another payer may be responsible for primary payment.
Subjective: This patient is a 45-year-old man. While working construction at a building site, he fell two stories from scaf-folding onto a concrete floor. He struck his head on the right side. Coworkers informed the EMS team that the accident occurred five minutes before their arrival. They further state the man had an immediate loss of consciousness, and he still had not regained consciousness when brought to the ED by EMS. EMS reports that he had some groaning, but was not talking during the 15-minute trip. He has been breathing on his own; and he has not been given any medications or treatments other than being back-boarded and placed in a cervical collar.
Objective: WDWN man, boarded and collared, making faint moaning sounds.
Vitals: T: 372, P: 80, R: 12, BP: 190/100. Airway is patent, but little gag, trachea midline. Breathing is shallow, but sym-metric, pulse ox shows 93% saturation. Circulations with good pulses radially bilaterally, establish access.
HEENT – Lac to right temporal scalp with hematoma, minimal bleeding, pupils equal with sluggish light reactivity, face and orbits without deformity, dentition intact, TM without hemotympanum.
NECK – No obvious deformity.
CHEST – Equal breath sounds with bagged, vented respirations, no crepitus, or deformity.
CARDIAC – RRR without murmurs, rubs, or gallops, strong peripheral pulses.
ABDOMEN – Soft, nontender, non-distended, diminished bowel sounds, no contusions.
PELVIS – Stable with AP and lateral compression.
SPINE – No obvious thoracic or lumbar step off or contusion.
RECTAL – Good tone (after succinylcholine wore off), prostate wnl, no blood.
EXTREMITIES – Slight deformity and contusion distal right wrist, no open wound.
NEURO – Flexion/withdrawal of extremities.
Ordered and Reviewed: C spine, CXR, and pelvis X-rays were performed, without injury, indicates good ETT placement, FAST – No free fluid, head CT – shows subdural hematoma.
S06.5X1A Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, initial encounter
R40.2341 Coma scale, best motor response, flexion withdrawal, in the field [EMT or ambulance]
R40.2112 Coma scale, eyes open, never, at arrival to emergency department
R40.2221 Coma scale, best verbal response, incomprehensible words, in the field [EMT or ambulance]
R40.243 Glasgow coma scale score 3-8
W12.XXXA Fall on and from scaffolding, initial encounter
Y92.61 Building [any] under construction as the place of occurrence of the external cause
Y99.0 Civilian activity done for income or pay
Based on the codes reported, you know exactly what happened to this patient, what condition he was in upon arrival to the ED, where he was when the accident occurred, and that this claim should be sent to the patient’s workers’ compensation payer.
Move Forward with ICD-10
Think of ICD-10 as a fresh new start. Let go of your fear of the transition, and shed any bad habits you may have developed over the years. Remember that good documentation + accurate coding = good business.
Shelly Cronin, CPC, CPMA, CPPM, CPC-I, CANPC, CGIC, CGSC, is director of ICD-10 training at AAPC.