Health Information Management

Q&A: Denials for different level of detail between surgeon, anesthesiologist in ICD-10-CM

JustCoding News: Outpatient, May 16, 2012

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QUESTION: We are a small anesthesia group and we are concerned about the specificity for ICD-10-CM. If we submit a claim with an unspecified code and the surgeon submits a claim with more specificity, will we still get paid?

ANSWER: This question has come up in discussions with major government payers but there is no definitive answer.

ICD-10-CM includes options for right, left, and unspecified for many conditions and injuries, including fractures. An anesthesiologist may document a fractured finger without specifying which hand or which specific finger. However, the physician needs to include that information for coders to accurately report the ICD-10-CM code.

Payer systems probably are not sophisticated enough to compare documentation from the anesthesiologist to documentation from the surgeon, especially since different practices or organizations submit two claims.

However, some payers do exclude unspecified codes routinely now as part of their payer policies. At this point, we don’t know for sure how payers will handle unspecified codes in ICD-10-CM. Payers may provide a grace period and reimburse for unspecified claims for a certain period of time after the switch to ICD-10-CM. On the other hand, payers may decide not to pay for any unspecified codes.

Editor’s Note: Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding at HCPro Inc., in Danvers, MA, answered this question during the “JustCoding Virtual Summit: ICD-10-CM and ICD-10-PCS.”

This answer was provided based on limited information that was submitted to JustCoding.com. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

Need expert coding advice? Submit your question to Senior Managing Editor Michelle Leppert, CPC-A, at mleppert@hcpro.com, and we’ll do our best to get an answer for you.



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