Health Information Management

I said what I meant and I meant what I said

HIM-HIPAA Insider, March 23, 2015

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We want physicians to be very clear in their documentation about what’s wrong with the patient and what the physician did to make that patient better. Our friends over at the Association of Clinical Documentation Improvement Specialists spend the

ir professional lives working to get more precise, detailed, accurate, no-room-for-interpretation documentation.

Why all the fuss about specificity? Different people interpret things different ways. My colleagues sometimes hate me for playing devil’s advocate and saying, someone could take that to mean Y instead of X.
Relevant case in point: Earlier this week, AHIMA emailed its members imploring them to call members of Congress to oppose an ICD-10 delay. AHIMA’s Margarita Valdez, senior director of Congressional relations, heard that Chairman of the House Rules Committee Pete Sessions, R-Texas, was drafting (or looking to draft) language for another ICD-10 delay.
My colleague Steve Andrews reached out to Sessions’ office asking for verification. In very short order, a member of Sessions’ staff replied that the Congressman is meeting with physicians about their concerns regarding ICD-10, but no legislation has been drafted.
I also heard from a blog reader who told me she had spoken to a staff member for Rep. Rob Woodall, R-Ga. That staff member had spoken to Sessions’ staff, who told him that Sessions has no plans at present to introduce legislation for another delay of ICD-10. (That’s a massive amount of hearsay, because it’s at best fourth-hand information, but still, we’ll take what we can get for now.)
At first glance, that looks like a win. No legislation, no delay, right? Not exactly. Here’s where playing devil’s advocate comes in.
Sessions had not drafted legislation and has no plans to introduce legislation. However, no one claimed Sessions isn’t looking to add language to an existing (or future) bill to delay ICD-10. It’s nitpicking, but we are talking about politicians.
The whole discussion may have started with a letter that the AMA and 99 specialty societies sent to Andrew Slavitt, acting administrator of CMS, detailing a “number of concerns that do not appear to be addressed” by CMS’ current transition plan.
Fair enough, we’re all worried about certain parts of the transition.
The medical groups want CMS to release more detailed end-to-end testing results broken out by:
  • Type and size of providers who tested
  • Number of claims tested by each submitter
  • Percentage of claims successfully processed
  • Specific details about problems encountered
That seems reasonable to me. The more we know about what worked and what didn’t, the better we can prepare.
Things get a little murkier near the end of the letter when it talks about code specificity. The AMA has been beating this drum for a while now because the increased specificity requires more detailed documentation. The detail, though, is one of the main strengths of ICD-10. We can get a better picture of the patient’s health, and with ICD-10-PCS, we’ll actually know what specific procedure the physician performed.
According to the letter:
CMS officials have stated that, absent indications of potential fraud or intent to purposefully bill incorrectly, CMS will not instruct its contractors to audit claims to verify that the most appropriate ICD-10 code was used. There is also general concern about how physicians will be audited as they learn to use the new code set. We urge CMS to: 1) confirm and broadly educate stakeholders and contractors that claims will not be audited simply for code specificity; and 2) to instruct contractors that they are prohibited from engaging in audits that are only predicated on code specificity.
I was kind of appalled by the apparent unconcern for specificity. Then I reread it and found it’s not so much appalling as it is vague. Then I went back to the source of the “no audit” statement, the Government Accountability Report on CMS’ preparation for ICD-10 implementation. According to that report:
CMS officials stated that the submission of valid ICD-10 codes is a requirement for payment; however, when the presence of a specific diagnosis code is not required for payment then the claim would be paid even if a more appropriate ICD-10 code should have been used on the claim.
In a way that makes sense. You could go to the physician’s office for a cold or a bad cut or just for your annual physical. In order to use the CPT® code for an office visit, you don’t need a particular ICD-10-CM code. You just need the code that will support medical necessity for that service. So if a patient is seen for S50.311A (abrasion of right elbow, initial encounter), you probably won’t get away with reporting CPT code 99215 (level 5 established patient visit).
The GAO report further stated:
Additionally, CMS officials indicated that, absent indications of potential fraud or intent to purposefully bill incorrectly, CMS will not instruct its contractors to audit claims specifically to verify that the most appropriate ICD-10 code was used. However, audits will continue to occur and could identify ICD-10 codes included erroneously on claims which could lead to claims denials, according to CMS officials.
The devil is in the details and the word choice. The GAO report states: “CMS will not instruct its contractors to audit claims specifically to verify that the most appropriate ICD-10 code was used.”
The medical societies’ letter uses different wording that actually doesn’t reflect what CMS said. The letter uses the phrase, “claims will not be audited simply for code specificity.”
Based on what CMS actually said, auditors could still go and look specifically for specificity. I wouldn’t be surprised if some third-party payer auditors did.
Note that CMS also said it will audit claims and the audit process itself could identify erroneous codes. It never details what makes the code erroneous, so theoretically, auditors could say the code is wrong because it’s not specific enough.
We also don’t know how or if CMS will reimburse for unspecified codes. You can absolutely use unspecified codes when they best reflect what is known at the time of the patient encounter or if the physician just doesn’t know what’s wrong. You can also use them when the physician doesn’t know the causative organism of a disease.
For example, a patient comes in with stuffy head, congestion, and wheezing. The physician listens to the patient’s complaint, her breathing, and her lungs, then diagnoses acute bronchitis. ICD-10-CM includes 10 codes for bronchitis, but in this case, you can report the unspecified one. The physician shouldn’t do a test just to get a more specific code.
Great, but what happens with E11.9? That’s the incredibly non-specific code for diabetes. In ICD-9-CM, it’s 250.00. Will CMS and other payers accept E11.9? If they do initially, how long will they continue to do so? Moving to a more specific code set does us no good if we don’t get more specific documentation.
Words matter and so does context. Make sure you read reports about ICD-10 as critically as you do physician documentation.
This article originally appeared on HCPro’s ICD-10 Trainer blog.

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