After a final review, I63. The official coding guidelines provide explicit guidance for appropriate uses of unspecific diagnosis codes. A diagnosis code rate over 30 percent requires investigation and appropriate corrective actions. Examples of some conditions most commonly reported with unspecified diagnosis codes are listed in the sidebar above. The user can turn the feature off when help is no longer required. The unspecified diagnosis code rate is calculated by dividing the number of unspecified diagnosis codes by the total number of diagnosis codes assigned.
One strategy to ensure unspecified codes are used appropriately is to monitor unspecified code rates and address any upward trends or outliers. In most cases the manifestation codes will have in the code title, 'in diseases classified elsewhere. There are different guidelines for each year, so when you access them, be sure you're using the guidelines for the correct year. The solution lies in addressing both improvements in the specificity of clinical documentation and process improvement to ensure medical coding professionals are coding to the highest degree of specificity that is available. It contains a more extensive vocabulary of clinical concepts, body part specificity, patient encounter information, and other components from which codes are built. Code Also A code also note instructs that 2 codes may be required to fully describe a condition but the sequencing of the two codes is discretionary, depending on the severity of the conditions and the reason for the encounter. Medicare Coverage Database — Overview The page could not be loaded.
Expert Ernie Hayden outlines the process. An Excludes2 note indicates that the condition excluded is not part of the condition it is excluded from but a patient may have both conditions at the same time. When overuse of unspecified codes is identified, solutions may involve improvements in the specificity of clinical documentation or process improvement to ensure coding professionals are coding to the highest degree of specificity that is available. The update contains 279 new codes and 143 revised codes and removes 51 codes, bringing the total number of codes to 71,932. Excludes1 A type 1 Excludes note is a pure excludes. Supporting documentation, particularly imaging reports, may be used to code to the highest degree of specificity when the physician has already documented a condition.
That would most likely happen in a hospital where a doctor who is not the one who usually treats you a hospitalist or with a doctor who reviews your records before he sees you. Instructional Notations Includes The word 'Includes' appears immediately under certain categories to further define, or give examples of, the content of thecategory. Wherever such a combination exists there is a 'use additional code' note at the etiology code, and a 'code first' note at the manifestation code. List additional codes that describe any coexisting conditions. When ordering, you should ensure you are ordering a code book that is not in draft form. Coding to the Highest Degree of Specificity While physicians are expected to document the most specific clinical diagnosis, it is equally important that coding professionals assign diagnosis codes to the highest degree of specificity documented. There is a disturbing amount of unspecified diagnosis code reporting when more specific diagnoses are documented in the health record.
The following coding examples demonstrate appropriate coding to the highest degree of specificity. The challenge for medical coders is to achieve a balance in productivity and quality to ensure that reported codes align with clinical documentation. They also include the counting of deaths as well as diseases, injuries, symptoms, reasons for encounter, factors that influence health status, and external causes of disease. Jacquie Zegan is senior coding consultant at United Audit Systems, Inc. The 7th character must always be the 7th character of a code. It is cited in more than 20,000 scientific articles and used by more than 100 countries around the world. Please visit the to view archived documents.
Review the clinical documentation on a targeted sample to confirm that the reported codes align with the degree of specificity in the health record. When an Excludes2 note appears under a code it is acceptable to use both the code and the excluded code together. If those two codes don't align correctly with each other, payment may be rejected. For certain codes, a seventh character is an extension digit and used to classify an initial, subsequent or sequela late effect treatment encounter. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.
As a final step in the coding process, coding professionals should perform a final review of the diagnosis codes on an encounter. This is an ongoing problem, even though the official guidelines for coding and reporting require coding to the highest degree of specificity. Again, be sure you download the codes for the correct year; 2014, 2015, 2016 and 2017 code sets are available. Diagnosis codes ending in the numbers zero or nine are often indications that an unspecified diagnosis code was assigned. After a final review, the code S92. Excludes2 A type 2 Excludes note represents 'Not included here'.
In the short term, it will increase claim denials, and in the long term it may adversely impact emerging payment models. Each note has a different definition for use but they are both similar in that they indicate that codes excluded from each other are independent of each other. The first three characters categorize the injury, and the fourth through sixth characters describe in greater detail the cause, anatomical location and severity of an injury or illness. In other words, if the service isn't one that would be typically provided for someone with that diagnosis, the doctor won't get paid. . The unspecified code rate is not an error rate, but rather an indicator of the quality of clinical documentation and a qualitative measure of coder performance and coding results. Government site for people with Medicare, for the latest information on Medicare enrollment, benefits, and other helpful tools.
Toward this aim, providers may need assistance—in the form of provider education or clinical queries—to recognize relevant clinical details that may impact the specificity of code assignment. Unfortunately, nonspecific documentation and coding persists. S Department of Health and Human Services. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. The alphabetical index is an alphabetical list of terms and the corresponding codes, and the tabular list is a structured list of codes that is divided into chapters that are based on a body system or condition. Overuse of Unspecified Diagnosis Codes Overuse of unspecified diagnosis codes is a problematic trend. Uses include monitoring of the incidence and prevalence of diseases, observing reimbursements and resource allocation trends, and keeping track of safety and quality guidelines.
High unspecified diagnosis code rates may be due to either clinical documentation or coding practices. Read for strategies to offset these threats and for. Third-party payers are making payment determinations based on the specificity of reported codes, and payment reform efforts are formulating policies based on coded data. A code will be considered invalid if it has not been coded to the full number of characters required, including a seventh character if applicable. People with Medicare, family members, and caregivers should visit , the official U. It provides a level of detail that is necessary for diagnostic specificity and morbidity classification in the U. A quick second review of the clinical documentation associated with these codes may reveal clinical details needed to derive a more specific diagnosis code.