Cut your High Rate of Unspecified Coding Denials

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Although ICD-10 has been in use for several years, problems with unspecified coding and the subsequent denials they trigger persist. Fortunately, unspecified coding denials can be easy to remedy for coders when they are given the complete picture of the encounter. Unfortunately, clinicians often don’t understand how poor documentation can leave coders with no other choice but to use an unspecified code.

It is essential to understand what unspecified codes say to insurance companies in order to fully understand why they so often trigger denials.

What unspecified codes really mean

In a nutshell, anytime an unspecified code is recorded on a claim, it is telling the payer that the case is so exceptional, it cannot be defined. According to The American Health Information Management Association (AHIMA), documentation must reflect the full extent of clinical knowledge. Therefore, these codes are saying that there is something about the condition that is unknown.

Sometimes unspecified codes are appropriate

There are times when unspecified codes are applicable – for instance, in cases of poisoning when the agent can’t be determined or with certain diseases and viruses. Overall, most providers that are practicing day-in-and-day-out medicine should be using unspecified codes as an exception rather than the rule.

The financial consequence of unspecified coding

Unspecified codes can trigger outright denials that need to be resubmitted and additional documentation requests (ADRs) that are time-consuming to resolve – resulting in increased labor costs. Another costly danger of unspecified claims is the risk of timely filing write-offs when responses to ADRs are delayed.

Considering the root causes of unspecified coding, most claim problems are avoidable.

Documentation omissions often result in unspecified codes

ICD-10 expanded diagnosis codes from the prior ICD-9 set of approximately 13,000 to around 68,000. That means the new codes contain a level of specificity that didn’t exist before the update, and the only way to code to that level of specificity is to have the information documented in the patient record. Generally, some broad categories help define specificity. They include:

  • Laterality
  • Specific body sites
  • Prior history
  • Circumstances (intentional or accidental)
  • Initial or subsequent encounter

Including information about the general categories will often give coders the information they need to code to the highest level of specificity.

Coders need to dig a little deeper

Of course, there are instances when documentation that defines specificity is contained in the patient record, but overlooked by coders. For example, a patient encounter only states shoulder pain, but a radiology report tied to the visit finds a hairline fracture of the right scapula. Therefore, the fracture should be the diagnosis rather than the pain in the shoulder.

In addition to looking through documentation to find answers, it can be helpful for coders to have more than one resource to help code.

Coding resources can help define specificity

There are many resources available to help coders capture the correct ICD-10 code. Free resources to aid coders are available from CMS at https://www.cms.gov/Medicare/Coding/ICD10/ICD-10Resources. However, many practices use coding software for its convenience, accuracy and efficiency.

For example, Centricity® offers a function that uses an easy-to-understand stoplight system to help providers determine if there is an acceptable level of specificity on the claim. A click of the mouse accesses the full list of ICD-10 codes to search. The codes can then be refined further to enhance specificity and can account for clinical attributes such as anatomical site, causative agent, specific episode of care, laterality, etc. A green light appears when billable specificity levels are achieved.

Get to the bottom of your unspecified coding issues

There are some simple, but effective steps you can take to minimize the use of unspecified codes:

1.  Audit denials

Regularly run denial reports to pinpoint problem coding. Plan on tackling the codes with the largest percentages of denials first.

2.  Review documentation

Pull patient records for the selected denied codes to confirm the encounter notes contain all required information for coding to the highest degree of specificity. If critical information is missing from the record, provide training to providers to ensure awareness of the information needed for correct coding. Retrain coders that are missing vital information contained in the patient notes to avoid unspecified codes in the future.

3.  Continually monitor

Coding definitions change and many practices have staff turnover. Continual monitoring of denials and documentation allows corrective action to be taken immediately – keeping labor costs low and revenue flowing.

Want to learn more about how VOWHS can help you avoid unspecified code denials? Contact us today at (412) 424-2260 or visit us at www.vowhs.com.

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