Wiki Unspecified Codes

[krystle8402]

I work for a Hospitalist group. I'm finding that it's hard to have more specificity with some codes. For instance, anemia, unspecified D64.9. Insurance companies are denying these claims even if it's the 5th dx on the claim. I'm curious to know how others are handling this. It also happens with COPD patients. They may not be COPD with acute exacerbation, but we can't use J44.9.

Thanks

 

[danskangel313]

I work for a Hospitalist group. I'm finding that it's hard to have more specificity with some codes. For instance, anemia, unspecified D64.9. Insurance companies are denying these claims even if it's the 5th dx on the claim. I'm curious to know how others are handling this. It also happens with COPD patients. They may not be COPD with acute exacerbation, but we can't use J44.9.

Thanks

One thing to remember is that the guidelines for "with" "in" "due to" changed on 10/1/16:

"The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the alphabetic index, or an instructional note in the tabular list.

The classification presumes a causal relationship between the two conditions linked by these terms in the alphabetic index or tabular list. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states that the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related."

For anemia, there are ton of terms under it. For Anemia>due to (in) (with) and Anemia>with (due to) (in), there are tons of terms there as well. If there is any condition listed under Anemia, the guidelines allow for the causal relationship.

COPD is basically a blanket term for any number of progressive lung diseases. The main types being emphysema and chronic bronchitis. Certain types of asthma would also be included. You would use the unspecified J44.9 if the provider doesn't diagnose a more specific classifiable condition.

It's also worth noting that words in parentheses are nonessential modifiers; they are "supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned."

For example, the code descriptor for J44.1 is "Chronic obstructive pulmonary disease with (acute) exacerbation". Because the word "acute" is a nonessential modifier, J44.1 can also mean "Chronic obstructive pulmonary disease with exacerbation." J44.1 also includes Decompensated COPD.

 

[mitchellde]

I work for a Hospitalist group. I'm finding that it's hard to have more specificity with some codes. For instance, anemia, unspecified D64.9. Insurance companies are denying these claims even if it's the 5th dx on the claim. I'm curious to know how others are handling this. It also happens with COPD patients. They may not be COPD with acute exacerbation, but we can't use J44.9.

Thanks

Unspecified codes are not necessarily always unacceptable. If there is a reason you had to use unspecified then you appeal the denial with the rationale. If the provider did not document thoroughly then that is not a good rationale. If the provider knows that the patient has anemia, for instance per blood test, but has not yet performed additional studies to know the specific type of anemia or the cause, then unspecified is what you will have and it is perfectly allowable. Many payers simply put a blanket edit in now that the grace period is over making claims with any unspecided diagnosis reject. An example of an unacceptable unspecified and you can never appeal is the unspecified body part.therovider should always know which body part is being addressed.

 

[krystle8402]

The provider may not know what type of anemia, so they just state anemia. . .so then I have nothing else to use other than D64.9. However the insurance companies are denying it. But, I'm getting this information from the billing office who does the appeals, so maybe it's because they don't want to have to do the appeals. The hospitalist group is a different "beast" because we're not the patient's PCP, and just deal with what is going on while they're in the hospital. Another problem I have is with pneumonia, cultures may not be back yet to specify which type of pneumonia. But you brought up a good point with the appeals, because it may just be that the billing office doesn't want to do those.

 

[mitchellde]

Yes they will need to be appealed. Pneumonia is another good example. Infections the provider may diagnose based only on the patient and presenting symptoms. It is not a requirement to even perform cultures or any other diagnostic study, therefore unspecified is often the correct diagnosis. Ask yourself this.. is it possible for the provider to know that this diagnosis exists and yet not have the information at hand to be more specific. If so then why is that information not available. If it is because the result is not back or the study has yet to be performed then unspecified is a logical option.

 

[krystle8402]

I absolutely agree! I told my providers about the specificity codes, and they basically said the same thing. This helps to confirm what I had been thinking and getting "frustrated" about. Thank you!!