Know when to report an unspecified code

To report an unspecified code or to query, that is the question.

 

And like so many coding questions, the answer is, it depends.

 

ICD-9-CM is full of not otherwise specified (NOS) codes. Think of those as not otherwise satisfied. An NOS code really means nothing.

 

Coders often default to the unspecified code because physicians don’t give them enough information. For example, if the physician documents diabetes, coders just assign 250.00 (diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled). 

 

Facilities need to review how often their coders assign NOS codes overall and by physician. That will get you to the physicians you need to train.” It can also tell facilities whether the coders need training as well. The physician may be documenting the information, but the coder doesn’t pick up on it.

 

One physician may account for a large number of NOS codes. In that case, the facility can focus on training that particular physician on what is lacking in his or her documentation.

 

On the other hand, the majority of physicians may not be documenting one specific condition well. For example, they may be writing simply “diabetes” in every diabetic patient’s chart. Instead of querying every time a physician documents “diabetes,” the facility can train its physicians on what coders need to see in the documentation.

 

In many cases a diabetes diagnosis will not affect MS-DRG assignment, which means coders probably don’t need to query for it. However, diabetes with ketoacidosis (250.1x), diabetes with hyperosmolarity (250.2x), and diabetes with other coma (250.3x) are all MCCs in ICD-9-CM, which will affect MS-DRG assignment.

 

Before sending a query, coders need to make sure it is clinically relevant, says Adele Towers, MD, MPH, associate professor of medicine and psychiatry and medical director of HIM for the University of Pittsburgh Medical Center.

 

Coders also need to review the entire chart before sending a query, Towers adds. “If you have the specificity in one place, you don’t want to bother the physicians if it’s not specified elsewhere.”

 

An unspecified code does not provide much information about the patient’s actual condition and it really does not support medical necessity for a patient’s treatment.

 

A payer may ask, “If you can’t tell me why you are taking someone to the operating room, why should I pay you?” says Joanne Schade-Boyce, BSDH, MS, CPC, ACS, PCS, director of education and curriculum for HRAA in Plantation, Fla.

 

Lack of payment is a big concern with unspecified ICD-10-CM codes. Payers have not yet stated whether they will continue to pay for unspecified codes in ICD-10-CM.

 

ICD-10-CM codes, in general, include a higher degree of specificity than ICD-9-CM codes. Many in the healthcare industry are worried that the increased specificity will lead to more queries.

 

That could lead to lower coder and physician productivity, and higher rates of Discharged Not Final Billed cases. Coders would spend more time querying, physicians would spend more time answering queries, and the chart would stay in limbo at the facility instead of being sent to the payer.

 

However, ICD-10-CM does include unspecified codes and default codes, just like ICD-9-CM, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of coding and HIM for HCPro in Danvers, Mass.

 

For example, if a physician does not document whether a patient’s diabetes is type 1 or type 2, coders still default to type 2 in ICD-10-CM. If the physician merely documents “diabetes,” coders would report E11.9 (type II diabetes without complications).

 

However, the codes for diabetes in ICD-10-CM are much more detailed than those in ICD-9-CM. Many ICD-10-CM diabetes codes include manifestations, so they are combination codes, McCall says.

 

If the physician documents “patient has type 2 diabetes with diabetic neuropathy,” coders would report one ICD-10-CM code (E11.21) instead of the multiple codes required in ICD-9-CM.

 

Not all ICD-10-CM unspecified codes are created equal. For example, a physician admits a patient with respiratory failure. In ICD-9-CM, coders default to acute respiratory failure (ICD-9-CM code 518.81), McCall says.

 

ICD-10-CM includes unspecified codes for respiratory failure, but the physician must state whether the respiratory failure is acute or chronic. 

 

One thing that physicians should always document is laterality, says Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC, vice president of ICD-10 education and training for AAPC in Salt Lake City. ICD-10-CM codes that require laterality also include an option for unspecified. “If the physician can’t tell you right or left, then you shouldn’t get paid,” she says.

 

The good news is many physicians already document laterality. Coders just don’t need to look for it in ICD-9-CM. To report otalgia in ICD-9-CM, coders use 388.70. In ICD-10-CM, they will have four choices:

If the physician didn’t document laterality, query before submitting an unspecified ear, Buckholtz says.

 

According to the ICD-10-CM guidelines, signs/symptoms or unspecified codes sometimes best reflect a patient encounter. That being said, coders should always code to the highest level of specificity. Don’t simply default to a nonspecific code to get the bill out the door.

 

However, sometimes physicians can’t come up with a definitive diagnosis. They just can’t say what’s wrong with the patient. Maybe they are waiting for a lab test or a radiology report. Maybe the patient’s symptoms are so vague the physician can’t pick a single diagnosis. Or two conditions could be so similar the physician can’t choose.

 

When the physician can’t assign a definitive diagnosis, coders should report codes for sign(s) and/or symptom(s). Remember, though, if the physician documents a definitive diagnosis, coders can’t code signs or symptoms that are integral to the diagnosis.

 

A patient comes in complaining of lower right quadrant abdominal pain. The physician’s job is to find out more about the abdominal pain, says Michael Gallagher, MD, MBA, MPH, CMO/CMIO of HRAA. “If the physician’s best documentation results in an NOS code, the physician is not documenting well.”

 

If the documentation is poor, coders should consider querying for additional information.

If the physician can’t determine the cause of the pain, report ICD-10-CM code R10.31 (right lower quadrant pain).

 

What happens if the physician documents the patient has acute appendicitis with lower right quadrant pain and generalized peritonitis? Coders would report K35.2 for the appendicitis, but not R10.31. Abdominal pain is an integral symptom of appendicitis.

 

ICD-10-CM also includes plenty of details about infectious diseases, including causative organisms (think botulism or salmonella) or types (such as pneumonia).

 

If a physician diagnosis a patient with pneumonia, but doesn’t know the specific type, coders should assign an unspecified code (J18.9, pneumonia, unspecified organism).

 

Report an unspecified code when it most accurately reflects what the provider knows about the patient’s condition at the time of a given encounter. Do not select a specific code that is not supported by the medical record.

 

It is also inappropriate for a physician to conduct medically unnecessary diagnostic testing in order to determine a more specific code, according to the ICD-10-CM Official Guidelines for Coding and Reporting. As a result, coders could end up reporting an unspecified code for a condition such as whooping cough (A37.9-).