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February 1, 2018

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ICD-10-CM/PCS News Archives

What the New ICD-10 Grace Period Means for ICD-10 Unspecified Coding

August 19, 2015:

The Centers for Medicare and Medicaid Services (CMS) recent announcement of an ICD-10 coding “grace period” related to specificity for part B physician claims has put a spotlight on unspecified ICD-10 codes. According to a recent review of 30,000-plus dual-coded inpatient/outpatient cases, coding and documentation review specialists have reason to worry.

ICD-10 proponents say the coding system’s greater specificity will capture more meaningful clinical detail. The grace period is intended to provide physicians and supporting staff billing under Medicare Part B with more time to learn ICD-10 without penalizing them for certain code specificity errors. Skeptics say it’s a burden with limited value.

Review reveals high percentage of documentation that can only support unspecified codes. Optum360 analyzed unspecified code use patterns of several hospital and physician organizations participating in an ICD-10 early adopter program using its computer-assisted coding solution. For approximately 12,500 inpatient cases, 26.2 percent of assigned ICD-10-CM codes were unspecified. Similarly, for approximately 20,500 outpatient cases, 28.7 percent of assigned ICD-10-CM codes were unspecified.

In most cases, unspecified codes are used when more specific medical record information is missing. Various diagnosis codes descriptions can be categorized as unspecified, including laterality, body location, trimester, type of condition, severity, underlying organism, etc.

ICD-10-CM and ICD-10-PCS differ in their approach to unspecified codes.ICD-9-CM and ICD-10-CM are similar in unspecified codes. A comparison shows that 20.9 percent of ICD-9-CM codes define “unspecified;” it’s 32.0 percent for ICD-10-CM. Laterality accounts for nearly 13,000 unspecified ICD-10-CM codes. Conversely, unspecified codes do not exist in ICD-10-PCS.

The significant percentage of unspecified ICD-10-CM codes does not show how often those codes will be used. Ideally, medical records should include directives to assign more specific codes. There is concern that physicians must spend additional documentation time to meet the new ICD-10 coding requirements. The grace period is intended to help alleviate that concern.

What’s the bottom line? Provider organizations have some important takeaways from the CMS clarifications:

  • Providers should be familiar with carrier policies and the specificity requirements within those policies. The grace period will not relax the requirements of NCD and LCD policies.
  • Hospital and physician organizations coding in ICD-10 are using a relatively high level unspecified ICD-10-CM codes, including those for laterality. Opportunity is there to improve documentation to reduce some unspecified code usage and include clinically relevant information.
  • For hospitals, the requirements for specificity in ICD-10-PCS coding do not support unspecified yet valid codes. Physicians working in the inpatient setting will be affected by PCS coding requirements.


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