Why Non-specific Codes Are a Non-issue
A safe harbor or grace period that would allow the submission of “less specific” ICD-10 codes after the ICD-10 transition continues to be raised as a way to alleviate the burden of the transition on physicians. For example, HR 2247, the ICD-TEN Act, would prohibit Medicare from denying claims “due solely to the use of an unspecified or inaccurate subcode.” A letter to the Centers for Medicare & Medicaid Services (CMS) from several members of Congress recommends that CMS indicate “whether claims must include the ICD-10 diagnosis code with the highest level of specificity immediately upon the October 1, 2015 effective date, or whether a clinically accurate but less granular code will be accepted. This letter further recommends that a “period during which less specific codes are accepted while providers get accustomed to the new system would be appropriate.”
In considering this issue, it is essential to understand that both ICD-9 and ICD-10 are structured so that there is always a “clinically accurate but less granular code” available. Under ICD-9, Medicare has ALWAYS accepted “less specific” codes, and providers are well-accustomed to the level of specificity required. During the transition to ICD-10, the level of specificity required will be no different than is currently required under ICD-9. CMS has reiterated numerous times that their acceptance of unspecified codes will not change as a result of the ICD-10 transition. For example, see this MLN Matters article on information and resources for submitting correct ICD-10 codes to Medicare.
Furthermore, it would be inappropriate and a violation of coding rules to require a level of specificity that is not documented in the medical record. Indeed, CMS has made it abundantly clear that it would be inappropriate to select a specific code that is not supported by the medical record documentation or to conduct medically unnecessary diagnostic testing in order to determine a more specific code. The ICD-10-CM Official Guidelines for Coding and Reporting state:
“Each healthcare encounter should be coded to the level of certainty known for that encounter …… When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate ‘unspecified’ code. Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient’s condition at the time of the particular encounter.”
To reiterate for emphasis, “it is acceptable to report the appropriate ‘unspecified’ code”. This is the official policy approved by CMS. All HIPAA-covered entities are required to abide by this policy because it is part of the official HIPAA ICD-10 code set standard. We are unaware of any payers that have stated an intention to violate this policy and disallow unspecified codes. Thus, the issue of the level of code specificity required is a non-existent problem.
The meaning of “subcode” in the ICD-TEN Act is not clear, although it has been suggested that “subcode” refers to the characters after the decimal point in an ICD-10 code. However, the characters after the decimal do not represent optional pieces of additional information. A code is invalid if it is missing any of the applicable characters, including those after the decimal point, just as the area code “312” by itself is not a valid phone number. All of the characters before and after the decimal are required to have a valid ICD-10 code and the characters after the decimal point are not analogous to CPT modifiers, which may or may not be appended to the base CPT code depending on the given situation. Also, information provided in the characters after the decimal point is not limited to highly specific details such as laterality or anatomic site. The nature of the disease or injury itself may also be described in characters after the decimal. For example, “Other disorders of muscle” (M62) provides no information about the type of muscle disorder – the characters after the decimal provide that information, such as rupture of muscle, contracture of muscle, or muscle spasm.
Calls for a safe harbor or grace period based on code specificity appear to be a reaction to physicians’ fears that there will be a huge uptick in claims denials if non-specific codes are reported. However, these fears are refuted by the results of CMS’ recent end-to-end testing, which showed only a 2% denial rate associated with ICD-10-related errors, thus demonstrating that the transition to ICD-10 will have a minimal impact on the rate of claims denials. Clearly if CMS had rejected all the claims containing non-specific codes, the ICD-10 rejection rate would have been much higher. A safe harbor for the use of non-specific codes is unnecessary and detracts industry attention from getting ready for the ICD-10 compliance date. There is no evidence supporting the need for a safe harbor. Unfortunately, the proposals to create a safe harbor for the use of less specific codes increase physicians’ fears and anxieties around the ICD-10 transition because they erroneously imply there is the possibility of widespread claims denials due to use of nonspecific codes. “We fear things in proportion to our ignorance of them.” (author Christian Nestell Bovee)
As an example of the appropriate use of an unspecified code, if the only available information is that the lower leg is fractured, without specification of the type of fracture or specific bone involved, there are codes for unspecified fracture of left and right lower leg and even a code for unspecified fracture of unspecified lower leg (although one would hope that at least left or right side would be in the clinical documentation). If specific details about the type of otitis media are unknown, there is a code for unspecified otitis media. And even if there is no “unspecified” code, there are default codes designated for use when specific clinical details are unknown. For example, while there is no code for fracture of unspecified part of tibia, the index makes it clear that a code for fracture of the shaft of the tibia should be assigned when the part of the tibia involved in the fracture is not specified.
Using less specific diagnosis codes is not ideal and adversely impact the quality of healthcare data, and so every effort should be made to capture the most complete clinical documentation to support the most specific code. But when no more information is known about the clinical condition to assign a more specific ICD-10 code or the information simply isn’t available, providers should report the appropriate less specific code, without fear of a Medicare denial solely on the basis of the specificity of the reported code – just as they have been doing under ICD-9.