Know How Unspecified ICD-9-CM Diagnosis Codes Could Hurt Your Practice’s Bottom Line

Lisa Eramo September 13th, 2012

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Unspecified diagnosis codes don’t provide any definitive information to payers, some of which will look for any reason to deny the medical necessity of services that physicians render

Although ICD-9-CM includes unspecified codes, practices should avoid reporting them, when possible.


They don’t provide any definitive information to payers, some of which will look for any reason to deny the medical necessity of services that physicians render, says Betty Johnson, CPC, CPC-I, CPMA, CPC-H, CPC-D, director of ICD-10 development and training at the American Academy of Professional Coders in Salt Lake City.

Unspecified codes—when reported frequently—can definitely subject physicians to third-party audits, says Johnson. Physicians can easily get into trouble when they report level 4 or 5 E/M codes with unspecified ICD-9-CM diagnosis codes, for example. This is problematic because payers may assume that the patient’s vague and unspecified diagnosis doesn’t justify the medical necessity of the intense level of E/M provided. It’s also easy for payers to assume that if the diagnosis isn’t documented properly, then the E/M level might not be documented appropriately either, she adds. 

Aside from the potential financial ramifications, unspecified diagnosis codes also prohibit effective disease management and other research efforts, says Johnson. 

It will become even more important to avoid unspecified codes once ICD-10 takes effect in 2014. That’s because ICD-10 includes more granular codes, and payers will likely question physicians who aren’t taking advantage of this added specificity, says Johnson.

For example, although ICD-10-CM does provide an unspecified option for otitis media (H66.90, otitis media, unspecified, unspecified ear), this code is so non-specific that it will most certainly raise a payer’s red flag, says Johnson. Instead, physicians should document laterality (i.e., whether the ear infection is in the left or right ear), which is not currently required in ICD-9-CM. Simply stating ear infection won’t be sufficient.  

Likewise, ICD-10-CM does provide an unspecified option for asthma (J45.90-, unspecified asthma); however, physicians should avoid this code. Instead, they should document whether the asthma is mild, moderate, or severe as well as whether it’s intermittent or persistent. This will enable coders to report a more specified option, says Johnson.  

Looking ahead

It’s too soon to tell how unspecified codes may affect physician reimbursement in 2014 and beyond because ICD-10-CM is vastly different than all of the other code sets that precede it, says Johnson. Even today, physicians are very dependent on each payer’s policy. Some payers may shift payment patterns for unspecified codes much more drastically than others. Some may deny claims entirely while others may require more documentation.  

The good news is that physicians don’t necessarily need to document paragraphs of additional information. One or two terms (e.g., acute or chronic) can make a big difference in terms of coders being able to report a more specified code, says Johnson.  

Johnson says that ICD-10 may eventually help with the adjudication process and reduce the number of denials that physicians receive simply because codes are more specific, and they tell the patient’s story more effectively.  

What you can do now

Talk with your larger payers. Ask your payers whether they’re looking more closely at unspecified codes. If not, does the payer plan to do so in the future once ICD-10 takes effect? 

Re-evaluate your templates. Can your EMR vendor make your templates more specific? Is there a user group that you can join to connect with other physician practices and better understand what your vendor might be doing to prepare for ICD-10? 

Ensure that coders have access to medical records when coding. Some physicians may document a more specific diagnosis in the record but not on the encounter form. If coders don’t have access to the records, they must default to an unspecified code in these instances, says Johnson.

Lisa A. Eramo is a freelance writer and editor specializing in medical coding, health information management, and other healthcare regulatory topics. Visit her website at Lisa wrote recently for Getting Paid on How Will Your Practice Transition Its Superbill to ICD-10?, Take a Closer Look at Your Superbill to Ensure Accurate Billing and Prevent Denials with More Accurate Medical Coding. Lisa has also written on Understanding RVUs: Ensure Accurate Reimbursement for the E/M Services You Provide.

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