Physician Practice

Confronting unspecified codes after the end of the ICD-10-CM grace period

Physician Practice Insider, April 18, 2017

When CMS negotiated the one year of leniency with the American Medical Association, it was a bad decision. First, it allowed providers to be less conscientious about their diagnosis coding. The compromise gave a one-year grace period to October 1, 2016, to allow providers to become comfortable with the ICD-10 coding system and to focus on the first three characters for medical necessity.

However, what happened is that some providers took the compromise as a license to map their superbill codes to and submit “not otherwise specified” (NOS) and “not elsewhere classified” (NEC) codes to all payers.

Of course, for those of us that understand the coding rules, we realize that NOS and NEC have two distinct meanings. So now some of the providers have built themselves a profile with their payers that is filled with NEC codes. This condition will surface a red flag to request records to find out what is actually being treated by that provider since most of his or her patients can’t be classified in a coding classification of more than 70,000 diagnoses.

Next, the one-year of leniency encouraged the submission of unspecified codes for Medicare patients, and of course, any other payer’s patients because we would not expect the coding practices to differ for a single office or clinic for different payers. And if there was no querying to clarify the diagnoses, then the unspecified codes were submitted. Commercial payers and some Medicare payers rejected and denied claims. Chemotherapy visits without a specific cancer were rejected within days of implementation. Similarly, surgeon claims lacking specificity for their surgeries were unacceptable.

This article originally appeared on JustCoding. Read the full, detailed article here.

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