As the transition to ICD-10 fast approaches, it will become important for providers to begin considering the use of unspecified codes to best describe a patient's conditions, which may be ambiguous due to the available documentation.
Most in the industry agree that the entire point of transitioning to ICD-10, is to provide more detail in order to drive better health outcomes and ultimately reduce healthcare expenses. The question is; how will payers respond to a claim submitted with unspecified codes, rather than a more specific ICD-10 code?
Payers have never adjudicated ICD-10 claims and will be learning as ICD-10 implementation happens. We do not know how payers will handle these unspecified codes, but practices need to be prepared to respond as they get feedback from the payers. An additional complication is that all payers will not handle these codes the same way at the same time. Therefore, it is important to be aware of the thin line separating the need to use unspecified codes.
As an example, it would be inappropriate to select a specific code not supported by medical record documentation, or for that matter, conduct medically unnecessary diagnostic testing in order to determine a more specific code. Conversely, when sufficient clinical information isn’t known or available to assign a more specific code, it is acceptable to report the appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined, but not the specific type).
Since payer processing responses of claims with specific diagnoses are yet to be seen, it is prudent, for practices to be focused on improving their documentation to be more specific and thereby ensuring continued reimbursements.
Below are few examples of where clinical documentation improvement will likely be needed, to reach a more specific code:
Diabetes documentation must include:
- Type of diabetes
- Body system affected
- Complication or manifestation
- If a patient with type 2 diabetes is using insulin, a secondary code for long term insulin use is required
Neoplasms documentation must include:
- Malignant (Primary, Secondary, Ca in situ)
- Unspecified behaviour
- Location(s) (site specific)
- If malignant, any secondary sites should also be determined
- Laterality, in some cases
Asthma documentation must include:
- Severity of disease:
- Mild intermittent
- Mild persistent
- Moderate persistent
- Severe persistent
- Acute exacerbation
- Status asthmaticus
- Other types (exercise induced, cough variant, other)
Fracture documentation must include:
- Anatomic site
- Fracture type
- Displaced or non-displaced
- Open or closed
- Open fractures will be coded based on the Gustilo open fracture classification, which are grouped into three main categories designated as Type I, Type II and Type III. Type III is further subdivided into Type IIIA, Type IIIB, and Type IIIC.
- Episode of care (assigned as a seventh digit extension)
- A = initial encounter for closed fracture
- B = initial encounter for open fracture
- D = subsequent encounter for fracture with routine healing
- G = subsequent encounter for fracture with delayed healing
- K = subsequent encounter for fracture with nonunion
- P = subsequent encounter for fracture with malunion
- S = sequela (late effect)
Pregnancy documentation must include:
- Documentation of conditions/complications of pregnancy will need to specify the trimester in which that condition occurred. Some codes but not all specify trimester.
- If the condition develops prior to admission, the trimester at the time of admission is assigned.
- If the patient is hospitalized during one trimester and a condition/complication develops during the same hospitalization but in a subsequent trimester, the code for the trimester in which the complication develops is assigned.
- The provider’s documentation of “weeks” may be used to assign the appropriate ICD-10 code for trimester.
- Definition of trimesters:
- First trimester = less than 14 weeks, 0 days
- Second trimester = 14 weeks, 0 days to less than 28 weeks, 0 days
- Third trimester = 28 weeks until delivery
Below are links to resources that will provide additional detail and insights into the use of unspecified codes.