ICD-10 Update: Increased Scrutiny Coming

-->September 22, 2016Billing & Compliance Alerts

    By Matthew Harrison, RHIA, CPC, CCP

    Medac clients experienced tremendous success in the transition to ICD-10, with a claims processing error rate of less than 0.001% related to ICD-10 issues in the first 30 days.  While the initial transition was a success, changes are coming that require a renewed focus on documentation habits.

    One of the “sighs of relief” prior to the October 2015 implementation was CMS’ decision to relax their specificity requirements, allowing providers and billers to be paid as long as the selected code was in the right “family” of codes, even if it did not include the most detailed specificity of the patient’s condition.  This grace period ends October 1, 2016.

    What Does This Mean for You?

    There are two schools of thought here:

    The first is that it might not mean much.  Few other payers formally adopted the specificity grace period.  This suggests that we should see low denial rates for payers who have offered a grace period and higher denial rates for those payers who did NOT adopt the grace period, but that hasn’t happened.  In fact, we only saw ICD-10 specificity denials for a few isolated payers.  So the conclusion is this:  If your documentation is not leading to specificity denials today, there is little fear that it will lead to specificity denials in October.

    The second is that we know there are certain conditions consistently being documented without the greatest level of specificity, and these certainly could be placed under more scrutiny beginning in October.  I have included a list of the most common “unspecified” diagnoses sent to Medac below and the details needed to provide the greatest level of specificity according to ICD-10.  It would be wise to review and adjust your own documentation habits relative to these items:

    Unspecific DiagnosisAdditional Details Needed
    CataractType (age-related, juvenile, traumatic, drug-induced, secondary), Location (cortical, anterior subcapsular, posterior subcapsular, nuclear), laterality
    Abdominal PainType (tenderness or pain), location (quadrant, epigastric, periumbilical, generalized
    GastritisType (acute, chronic superficial, chronic atrophic, alcoholic), with or without bleeding
    HemorrhoidsDegree, with or without bleeding
    OsteoarthritisSite, type (primary, post-traumatic, secondary), laterality
    DiverticulosisSite, with or without perforation/abscess, with or without bleeding
    DysphagiaPhase where dysphagia is occurring
    Dental CariesType and location
    Atrial FibrillationType (paroxysmal, chronic, typical, atypical, persistent)
    AppendicitisAcute or chronic, with or without peritonitis
    Leiomyoma of UterusDepth (submucous, intramural, subserosal)
    AnemiaType (hereditary, siderobalstic, dysterythropoietic)
    Gastric UlcerAcute or chronic, with our without hemorrhage, with or without perforation
    OsteoarthritisSite, laterality, type (primary, post-traumatic, secondary)
    CholecystitisAcute or chronic
    Rotator Cuff TearComplete or incomplete
    HydronephrosisDocument any strictures and cause of hydronephrosis
    Malignant Breast CancerSite (quadrant, nipple, areola)
    OsteomyelitisSite, Type (acute, chronic, subacute)

    Medac will continue to monitor denials for ICD-10 issues and notify you of any specific documentation or payer trends.


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    The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author’s presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.