Unspecified diagnosis coding has continued to be a problem in the US healthcare industry, even following the October, 2016 expiration of the Centers for Medicare and Medicaid Services’ (CMS) year-long, post-ICD-10 implementation grace period.
For many organizations, overuse of nonspecific diagnosis codes has resulted in reimbursement delays and, in some cases, preventable claim denials.
In a peer-reviewed article published in this month’s edition of the Journal of the American Health Information Management Association (JAHIMA), UASI senior coding consultant Jacquie Zegan, CCS, RCC, outlined steps that health systems should take to improve their clinical documentation and coding practices and safeguard themselves against avoidable revenue losses.
Why Coding Specificity Matters
CMS has required providers to use specific diagnosis codes, to the degree that they are possible, since October 2016.
A certain amount of unspecified diagnosis coding will always be necessary; for cases in which there is not yet enough clinical evidence to support a more specific diagnosis, an unspecified diagnosis code must be assigned. And CMS allows for that.
CMS does not, however, allow provider organizations to rely too heavily on unspecified diagnosis codes in their billing. When a high enough threshold is reached, it will begin to deny claims:
“Third-party payers are making payment determinations based on the specificity of reported codes, and payment reform efforts are formulating policies based on coded data. The significance of over-reporting unspecified diagnosis codes cannot be understated. In the short term, it will increase claim denials, and in the long term it may adversely impact emerging payment models.”
Unfortunately, Zegan noted, many providers still fail to provide clinical documentation that supports coding specificity.
That trickles over to the coding and billing departments. Without the appropriate clinical documentation in the chart, coders must often resort to reporting unspecified diagnosis codes — those that include “unspecified” or “not otherwise specified (NOS)” in their code descriptions.
Does Your Healthcare Organization Have a Problem with Diagnosis Coding Specificity?
It could. Although non-specific diagnosis codes might be expected to comprise approximately a fifth of reported codes on an organization’s outstanding claims, some hospitals’ and health systems’ unspecified diagnosis code rates are, in CMS’s view, unacceptably higher:
“Unspecified diagnosis code rates can range anywhere from 20 percent, on the low end, to over 40 percent. A diagnosis code rate over 30 percent requires investigation and appropriate corrective actions.”
There is certainly an opportunity here for an organization’s health information management (HIM) and clinical documentation improvement (CDI) professionals to work together — and in partnership with the clinical and coding teams — to monitor the unspecified diagnosis code rate and take steps to reduce it.
Identify Outliers and Educate
Some chronic conditions — substance abuse, dementia, asthma, heart failure, etc. — are rather notorious for exhibiting high rates of non-specificity in charts.
Zegan recommended that healthcare entities seeing upticks in their unspecified diagnosis code rates pull targeted chart samples to “identify outliers” — particular service lines within the organization in which provider education might be needed to improve clinical documentation.
The lack of diagnosis coding specificity, she wrote, may be attributed to non-specific clinical documentation or missed opportunities in diagnosis coding specificity by the coder:
“Coding specificity is a shared responsibility between the provider and the coding professional to create a clear clinical picture of the encounter.”
The key to improving documentation and diagnosis coding specificity, Zegan suggested, is to foster open, two-way communication between providers, clinical documentation improvement specialists and coders:
“Providers have an obligation to document conditions to the full extent of their clinical knowledge of the patient’s health [and may] need assistance — in the form of provider education or clinical queries — to recognize relevant clinical details that may impact the specificity of code assignment.”
Could Your Organization Use Assistance in Reducing Its Unspecified Diagnosis Code Rate?
UASI has the coding and CDI expertise to support your efforts.
Our client-focused CDI consulting and education services can help your clinicians become more adept at recognizing the key, diagnosis-supporting details your coding team needs to submit appropriate claims, and improve their consistency in documentation practices.
Likewise, our skilled third-party coding professionals can alleviate backlogs and staffing shortages your organization may face, and free up your internal resources to re-focus on process improvement.
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