# Can anyone answer this question?



## Love Coding! (Nov 22, 2011)

Am I not providing enough information to the question that I have? 

Hello,

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


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## LLovett (Nov 22, 2011)

*Professional services are paid based on CPT not ICD codes*

Hospitals are paid based on ICD codes so they will push providers to get as specific as possible. 

The word in the industry is the insurance carriers are going to kick the unspecified ICD-10 codes. Whether or not that is true is unknown, we will have to wait and see.

Specificity is going to be highlighted big time in ICD-10 and while the professional side is not technically paid based on dx if the providers have to re-do documentation in order to support the new codes then that will cause them to lose financially. Re-work is not fun for anyone and providers are very time sensitive so going at it from that angle would be an accurate way to tie it to reimbursement. If that is the approach you are wanting to take.

Hope that helps,

Laura, CPC, CPMA, CEMC


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## ajs (Nov 22, 2011)

021402 said:


> Am I not providing enough information to the question that I have?
> 
> Hello,
> 
> ...



For Medicare Advantage plans, dx coding is how they get money from CMS to pay claims for their clients.  HCC (Hierarchial Condition Categories) are linked to about 3000 ICD-9 codes for chronic or acute conditions.  These must be reported every year to count in the Risk Adjustments for MedAdvantage patients.  The sicker the patient, the more codes that are reported, the more money that comes in from Medicare to cover their claims.  This applies to office and hospital claims!


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## donnajrichmond (Nov 23, 2011)

It can affect physician reimbursement if the procedure/exam being billed has an LCD or other medical policy that requires specific diagnosis codes and an unspecified code is used.  
As Laura said, as payers revise their policies for ICD-10-CM they may decide not to pay for many non-specific diagnoses. 
This could be a big problem for radiology because specific information is often not provided by the ordering physician/hospital.


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