The provider goal for this flexibility period is to identify all of the “unspecified codes” used on their claims, review the documentation, and determine the most appropriate code. The practice staff assigned to this task would then provide feedback to the physicians to enhance their future reporting strategies. Although “unspecified” codes are often reported by default, physicians and staff should attempt to reduce usage of this code type unless the patient’s condition is unable to be further specified or categorized at a given point in time.
For example, it would not be acceptable to report R10.8 (unspecified abdominal pain) when a more specific diagnosis code can be easily determined by patient history or exam findings (e.g. right upper quadrant abdominal pain, R10.11).
Affected Claims
As previously stated, “Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review.”3 The review contractors included are as follows:
- Medicare Administrative Contractors (MACs) process claims submitted by physicians, hospitals, and other healthcare professionals and submit payment to those providers according to Medicare rules and regulations (including identifying and correcting underpayments and overpayments);
- Recovery Auditors (RACs) review claims to identify potential underpayments and overpayments in Medicare fee-for-service, as part of the Recovery Audit Program;
- Zone Program Integrity Contractors (ZPICs) perform investigations that are unique and tailored to the specific circumstances and occur only in situations where there is potential fraud and take appropriate corrective actions; and
- Supplemental Medical Review Contractor (SMRCs) conduct nationwide medical review as directed by CMS (including identifying underpayments and overpayments).4
This instruction applies to claims that are typically selected for review due to the ICD-10-CM code used on the claim but does not affect claims that are selected for review for other reasons (e.g. modifier 25 [separately identifiable visit performed on the same day as another procedure or service], unbundling, service-specific current procedural terminology code). If a claim is selected for one of these other reasons and does not meet the corresponding criterion, the service will be denied. This instruction also excludes claims for services that correspond to an existing local coverage determination (LCD) or national coverage determination (NCD).
For example, an esophagogastroduodenoscopy (EGD) is not considered “medically necessary” when reported with R10.8 (unspecified abdominal pain) and would be denied. EGD requires a more specific diagnosis (e.g. right upper quadrant abdominal pain, R10.11) per Medicare LCD.
Non-Medicare Payer Considerations
Most payers that are required to convert to ICD-10-CM have also provided some guidance about claim submission. Although most do not address the audit and review process, payers will follow some basic principles:
- Claims submitted with service dates on or after October 1 must use ICD-10-CM codes.
- Claims submitted with service dates prior to October 1 must use ICD-9-CM codes; this includes claims that are initially submitted after October 1 or require correction and resubmission after October 1.
- Physician claims will be held to medical necessity guidelines identified by specific ICD-10-CM codes represented in existing payer policies.
- General equivalence mappings (GEMs) should only be used as a starting point to convert large databases and large code lists from ICD-9 to ICD-10. Many ICD-9-CM codes do not crosswalk directly to an ICD-10-CM code. Physician and staff should continue to use the ICD-10-CM coding books and resources to determine the most accurate code selection.
- “Unspecified” codes are only for use when the information in the medical record is insufficient to assign a more specific code.5,6,7
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is on the faculty of SHM’s inpatient coding course.