What is ‘Unspecified Coding?’
In 2015, the number of CMS medical billing codes went from about 13000 (ICD-9) to around 68000 (ICD-10). Clearly, the vast addition of codes was done with the intent of enhancing specificity in medical billing. In the initial period of transition to ICD-10, CMS was lenient with ICD-10 coding specificity, but that grace period ended on October 1, 2016.
While the use of unspecified codes was common under ICD-9, today the use of unspecified ICD-10 codes adversely impacts the possibility of a straight through approval of claim by the payer.
The use of unspecified codes indicates any one of the following to the payer –
- The medical condition is so unique that the coder could not find the specific code for it.
- The attending physician did not have the experience to accurately diagnose the health condition.
- There is an absence of medical reports at the time of billing. For instance, you have knowledge of the symptoms but are not able to comment on the patient condition at that point of time.
- It is a case of poor documentation by the physician, leaving the medical biller no choice but to use unspecified coding.
Let us be clear – unspecified codes still exist and are there for a reason. However, unspecified coding greatly enhances the chances of a claim being delayed or denied.
When are Unspecified Codes Used?
Unspecified codes should be used as an exception rather than the rule. Unspecified coding is typically used in the following conditions –
- When the claim is from a provider not directly involved in patient care.
- When the patient is in preliminary stages of evaluation.
- The physician is a generalist, and the diagnosis requires a specialist.
- The cause is unknown. For instance, when a poisoning agent cannot be determined, or there is unknown causing virus.
- Coding the symptoms, the patient is experiencing, instead of the diagnosis, is permissible in some cases.
How to Minimize Use of Unspecified Coding?
The use of unspecified codes can result in additional documentation requests (ADR’s) from the payer. It can also lead to claim denials, increase cost of medical billing, and worsen your claim write-offs. Here are some ways to minimize the risk of practice revenue losses from unspecified coding.
- Document as much as possible: Documenting additional information can help the medical coder define specificity. Add information on laterality, anatomical location, trimester of pregnancy, type of diabetes, pre-existing medical conditions and complications, description of severity, circumstantial information (intentional/ accidental), and whether it is an initial or follow-up diagnosis.
- Conduct claim denial audits: A regular audit of your claim denials will help you understand your cases of unspecified coding.
- A regular dialogue with your medical billing partner: A professionally managed RCM service will take the lead in discussing improvement of medical coding and billing for your practice. Leverage that relationship to stay up to date on changes in medical coding guidelines, claim documentation requirements, and payer specific guidelines on unspecified coding.
- Periodic trainings for in-house medical billing staff – If your billing is inhouse, ensure regular medical coding training for staff to ensure awareness of the information required for accurate coding. Here’s a link to CMS ICD-10 Resources.
Contact us today for assistance with unspecified coding, reducing denials, and improving claim collections.