Pulmonology Coding Alert

Avoid unspecified ICD-10 codes, CMS says.

Get ready to face the real brunt of the ICD-10 implementation, as the cushioning effect of Medicare flexibilities comes to an end this October, and your ICD-10 coding abilities will be subjected to the real grind. If you haven’t mastered the art of picking the most specific code from a sea of diagnosis options by now, you may have to face the music.

“For ICD-10 flexibilities, the local Medicare contractors have been revising policies over the past year, making coverage more specific,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. “Practices should have been reviewing these policies to familiarize themselves with the new specifications.”

On August 18, 2016 , CMS added information related to expiration of Medicare flexibilities to the existing document— “Clarifying Questions and Answers Related to the July 6, 2015, CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities” (https://www.cms.gov/Medicare/Coding/ICD10/Clarifying-Questions-and-Answers-Related-to-the-July-6-2015-CMS-AMA-Joint-Announcement.pdf ). Here’s a crisp summary of the must-know points that CMS wants to drive home.

The flexibility chapter comes to an end, and now CMS means real business. Come October 1, the year-long concessions will cease to apply, and CMS has made clear there would be no more extensions this time. What’s more — there will be no more additional flexibility guidance.

Get Ready For the End of Flexibilities

CMS urges you to avoid using unspecified ICD-10 codes, and make your best effort to report a more detailed code based on the documentation.

The sour truth: Do not expect Medicare to phase in the requirement to code to the highest level of specificity either. Providers are expected to have achieved competence in coding specificity by now. In fact, certain insurers did not choose to offer coding flexibility to begin with, so many providers are already using specific codes. Nevertheless, you will need to brace yourself so that your coding accurately reflects the clinical documentation in as much specificity as possible, in accordance with the requisite coding guidelines. “Keep ahead of the game,” says Pohlig. “Review payer policies quarterly, and do preparations for ICD-10 changes when the codes are released prior to their effective date.”

Can You Still Use Unspecified Codes? Find Out

While CMS requires you to report specific diagnosis codes as per the documentation, in some instances, you may have to resort to unspecified codes, when there is not much of information available.

“You should code each health care encounter to the level of certainty known for that encounter,” says CMS in the document. “When sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code (for example, a diagnosis of pneumonia, although the physician has not determined the specific type).”

Discover If NCDs and LCDs Will Be Overhauled

CMS and its contractors will update the NCDs and LCDs when the new codes are added and finalized. As for the 2017 update, you will not see an extensive overhaul. The reason being that 3,549 fresh codes, making up 97% of the total update are cardiovascular codes. These codes will not result in too many global changes to the existing NCDs and LCDs.

Visit the CMS ICD-10 website for transmittals that contain code updates for NCDs.

Ensure You Have Maximum ICD-10 Specificity

ICD -10 was implemented to bring forth a greater degree of detail and accuracy in diagnosis reporting. CMS advises you to avoid unspecified ICD-10 codes, when your documentation provides you with enough information for a more appropriate code. Double check each claim to ensure that it aligns with the clinical documentation.

“While this year’s update includes many new codes, the new clinical concepts are minimal,” says CMS in its clarification. CMS is well equipped to handle changes to codes and processes, so do not anticipate any delays.

Final takeaway: “ICD-10 coding should be handled in the same manner as ICD-9 was handled: keep up with payer policy changes; identify new/deleted/revised codes for each year, and implement these changes in the most effective and seamless way possible,” Pohlig says. “Don’t wait for a payer to deny your claims to identify coding or policy changes. If you wait until the effective date to update your coding lists and educate the providers/staff, you may find that transition a bit harder to handle.”