Guest Post: Addressing unspecified codes

By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS

When CMS told the American Medical Association (AMA) physicians could have a one-year grace period to become comfortable with ICD-10-CM/PCS coding systems, they made a bad decision. The agreement allowed providers to be less conscientious about their diagnosis coding, leaving them to focus only on the first three characters of the code for medical necessity purposes. In actuality, some providers took the compromise as a license to map their superbill codes and submit “not otherwise specified” (NOS) and “not elsewhere classified” (NEC) codes to all payers.

Matthew Menendez of White Plume Technologies estimated in 2016 the average rate of unspecified code use at the time was 31.5%.

“Payers want the more detailed diagnosis information available in ICD-10. The reason that both government and commercial payers advocated for the migration to ICD-10 and invested millions of dollars to rewrite their adjudication processes was for the granular diagnosis data on their insured patient populations. Payers want to leverage detailed ICD-10 codes to drive down the cost of healthcare in the United States and if the provider community does not supply this data they will begin to deny claims,” Menendez said.

The NEC cases, the NOS cases previously accepted by Medicare are now perfect targets for a retrospective review by any of the government contractors.

Since the grace period between CMS and the AMA ended September 30, 2016, CDI and HIM program managers should review physician practice records both prospectively and retrospectively.

Prospectively, audit a sampling of records to identify documentation deficiency trends pulling NEC and NOS records specifically and offering tips to physicians for documenting the necessary specificity. Target these records for the physician prior to the patient’s return, so the physician can be prepared to capture the necessary information concurrently while the patient’s being seen.

In some situations, though, a more specific condition may not be possible. If unspecified codes are applied to accounts, they should go through a second review process (pre-bill) by a more senior coder or the coding manager.

Retrospectively, coding managers should monitor the continual use of NEC and NOS codes to determine the magnitude of the issue. If greater than 5% of the claims fall into an unspecified bucket in any single payer group, it should be concerning and spur additional CDI educational outreach.

Editor’s note: This article is adapted from JustCoding’s Practical Guide to Coding Management. The views expressed do not necessarily represent those of ACDIS or its advisory board.