Unspecified ICD-10-CM laterality diagnosis codes
Did you read the FY2022 IPPS Final Rule? While it’s usually an effective cure for insomnia, there is an interesting tidbit regarding unspecified ICD-10-CM laterality diagnosis codes that may keep you up. Let’s take a deep dive and consider how it impacts our coding world.
BACKGROUND
We are all familiar with the ICD “unspecified” diagnosis codes; you know, the ones we fall back on when there just isn’t enough documentation to grab a more descriptive code. An ICD-10-CM code is deemed unspecified if either of the terms “unspecified” or “NOS” is included in the code description. Sometimes providers can’t be more specific because the patient’s work up is not complete, or the information is otherwise unavailable. Back in 2015, during ICD-10 implementation, payers considered denying all claims that were submitted with unspecified codes. Providers pushed back, arguing that the querying needed to eliminate the unspecified codes would have been overly burdensome. So, for the first 12 months of ICD-10 use, providers were allowed to use unspecified diagnosis codes without fear of claims denials. This flexibility was intended to help providers implement the new code set and was not intended to be permanent. In fact, this CMS-granted grace period expired on October 1, 2016. Some third-party payers have been denying unspecified codes for years.
Official Guidelines for Coding and Reporting state:
Other and Unspecified codes
“Unspecified” codes
Codes titled “unspecified” are for use when the information in the medical record is insufficient to assign a more specific code. For those categories for which an unspecified code is not provided, the “other specified” code may represent both other and unspecified.
Unspecified Laterality and FY2022 IPPS Changes
In the FY2022 Proposed Rule, CMS requested public comments on a potential change to the severity level designations for “unspecified” ICD-10-CM diagnosis codes. They were also requesting public comments on the potential creation of a new MCE code edit involving these “unspecified” codes. The edit would trigger when an “unspecified” diagnosis code currently designated as either a CC or MCC, that includes other codes available in that code subcategory that further specify the anatomic site, is entered. This sounds a bit confusing, but if you look at Table 6P.3a on the CMS website (linked below) you can see all the unspecified codes that would be subject to this edit. This MCE edit would signal to the provider that a more specific code is available to report. CMS believes this edit aligns with documentation improvement efforts and leverages the specificity within ICD-10.
In response to the FY2022 Proposed Rule comment period, many commenters requested a 2-year delay before implementing this edit so that providers could prepare. So, in the FY2022 Final Rule, CMS stated it will not change severity levels, meaning that unspecified codes used as CC/MCC for inpatient claims will still be allowed without impacting reimbursement. However, CMS DID finalize the following (I am quoting from the final rule):
“After consideration of the public comments received, we are finalizing the implementation of a new code edit for “unspecified” codes, where there are other codes available in that code subcategory that further specify the anatomic site. As noted previously, the severity level of the unspecified diagnosis codes is unaffected and therefore this edit does not affect the payment the provider is eligible to receive.
We also note that, in consideration of commenters’ concerns that more time is needed to educate providers, the implementation date for this new edit is April 1, 2022. As such, we are finalizing the new edit for FY 2022, effective with discharges on and after April 1, 2022. We are finalizing a new Unspecified Code Edit: to read as follows:
Unspecified Code Edit: Unspecified codes exist in the ICD-10-CM classification for circumstances when documentation in the medical record does not provide the level of detail needed to support reporting a more specific code. However, in the inpatient setting, there should generally be very limited and rare circumstances for which the laterality (right, left, bilateral) of a condition is unable to be documented and reported.
The list of codes subject to this edit are identified in Table 6P.3a associated with this final rule.
When a code from the list displayed in Table 6P.3a is entered on the claim, the edit will be triggered. It is the provider’s responsibility to determine if a more specific code from that subcategory is available in the medical record documentation by a clinical provider. If, upon review, additional information to identify the laterality from the available medical record documentation by any other clinical provider is unable to be obtained or there is documentation in the record that the physician is clinically unable to determine the laterality because of the nature of the disease/condition, then the provider must enter that information into the remarks section. Specifically, the provider may enter “UNABLE TO DET LAT 1” to identify that they are unable to obtain additional information to specify laterality or they may enter “UNABLE TO DET LAT 2” to identify that the physician is clinically unable to determine laterality.” If not entered, the claim will be returned.”
WHAT CAN PROVIDERS DO?
Audit! The only way to know how often you currently assign unspecified diagnosis codes is to know at what you are doing today. Most hospital EMR systems can generate aggregate data to begin the process without much effort. Calculate your unspecified diagnosis code rate by dividing the number of unspecified codes by the total number of diagnosis codes assigned. The data can be further drilled down to unspecified laterality codes. Armed with this information, the next step is to review the clinical documentation associated with these codes.
· Do your providers fail to document enough information to assign a more specific code?
Example: The provider documents a fracture of the distal phalanx of the ring finger, without indicating right or left hand.
· Do your coders (or providers, if they assign their own codes), fail to capture the detail within the documentation?
Example: Provider documents fracture of the distal phalanx of the right ring finger, but codes unspecified ring finger. This happens often when providers code their own outpatient visits and use a drop-down code menu that lists unspecified codes first. Most providers don’t have the time or expertise to drill down to a more specific code.
· Is there a disconnect between diagnostic testing orders and provider documentation?
Example: Provider documents fracture of the distal phalanx of the right ring finger in the office note but does not indicate laterality when ordering an x-ray.
We hope you find our analysis helpful. We always recommend that you read the updates yourself each year to stay on top of coding changes. Carry on Coders!
References
Final Rule: https://www.cms.gov/medicare/acute-inpatient-pps/fy-2022-ipps-final-rule-home-page
FY2022 Final Rule Tables:https://www.cms.gov/medicare/acute-inpatient-pps/fy-2022-ipps-final-rule-home-page#Tables