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The use of unspecified codes and reimbursement

  1. Default The use of unspecified codes and reimbursement
    Medical Coding Books

    I hope that someone can give me a good understanding on when to use an "unspecified" ICD-9 code and when not too.

    I am in the middle of a project regarding the cleanup of ICD-9 codes in my database. This database was created way before I started with my company. I am finding that 65-70% of the codes in the database are "unspecified". With some of the code sets not providing a more detailed code selection within that code set.

    Can someone explain to me how this affects reimbursement for a physician, when using the "unspecified" codes constantly? I will be teaching my physicians that with ICD-10 will require them to be much more specific and using the uspecified code usage could possibly hinder their reimbursement. Am I right to that thought?

    Any help would be greatly appreciated

  2. #2
    Jacksonville Florida Chapter
    I can only tell you what I was taught and even told from people who worked at places like Blue Cross Blue Shield.

    Using "unspecified" codes can cause an insurance company to wonder what's going on. To them, it's like your practice is trying to hide something in the hopes of getting more money since you're not being all that specific with your coding. And we all know what THAT can lead to. Can you say audit?

    You're right in thinking that more and more insurance companies will not pay if they catch your practice over using the "unspecified" codes and they will for sure if you do it too much. Sure... sometimes you don't have a choice because procedures change between updates and new diseases or variations of old ones are discovered all the time and that's why there are unspecified codes, but my understanding is that they should really be used sparingly.

    Besides... I've seen ICD-10 and the codes are even more specific than the ICD-9 codes. It's going to be interesting once the transition happens.

    It's my hope that you're physicians will start now being more specific with their Dx and even their procedures to get into the habit before the transition to ICD-10.
    John Meyer, CPC
    Heekin Clinic

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