December 22, 2015
When you are an auditor, you look for unspecified codes. It is in your blood; it is in your knowledge of coding. However, with the transition into ICD-10, we should all be very cautious when selecting an unspecified code. During the 2015 implementation, AMA and CMS came to an agreement that if you were in the "specified family" of codes, your claim would be paid without question, and there would be no auditing for this period. However, ICD-10 is a new, clean slate; a slate that will become tarnished with "unspecified" codes and the same routine and pitfalls we saw with ICD-9.
As an auditor, one code that stands out significantly is 285.9, Anemia, unspecified. Using the unspecified code leads us to the rationale that there is no other code within the anemia codes to describe the condition in which your patient has. As we look at "Anemia" in the ICD-10-CM, we will see that Anemia is significantly expanded for more reporting selections:
D50: Iron Deficiency Anemias D51: Vitamin B-12 Deficiency Anemias D52: Folate Deficiency Anemias D53: Protein Deficiency Anemias D55: Anemia due to Enzyme Disorders D60: Acquired Pure Red Cell Aplasia D61: Bone Marrow Failure Syndrome Anemias D62: Acute posthemorrhagic Anemia D63: Other Anemias (Including: Due to Antineoplastic chemotherapy, CKD, and Diseases classified elsewhere i.e., hookworm disease, malaria, tuberculosis)
A secondary code that remains chronically unspecified is 461.9, Acute Sinusitis, unspecified. As we take a more in-depth look at the ICD-10 selections for Acute Sinusitis, we will see that there are several connections that can be made to apply a more specific code:
J01.0: Acute maxillary sinusitis J01.1: Acute frontal sinusitis J01.2: Acute ethmoidal sinusitis J01.3: Acute sphenoidal sinusitis J01.4: Acute pan sinusitis J01.8: Other acute sinusitis (only to be used if the acute sinusitis involves more than one sinus but does not qualify for the diagnosis of pan sinusitis) J01.9: Acute sinusitis, unspecified
Another code that stands out to me as an auditor is 682.9, Cellulitis, unspecified. With the approach of ICD-10-CM around the corner, it is time to learn the more specified terms of cellulitis. With the implementation of ICD-10-CM, Cellulitis has become more specified with site and laterality and even severity:
L03.01: Cellulitis of finger (specified code by laterality of the cellulitis) L03.03: Cellulitis of toe (specified code by laterality of the cellulitis) L03.11: Cellulitis of other parts of limb (includes axilla, upper and lower limbs specified by laterality) L03.211: Cellulitis of the face (excludes: ear, eyelid, head, lip, mouth, nose, orbit and scalp) L03.31: Cellulitis of trunk (abdominal wall, back, chest wall, groin, perineum, umbilicus and buttock) L03.81: Cellulitis of head (any part, except face)
The use of 214.9, Lipoma, unspecified is also of great concern in the auditing realm. Within the ICD-10-CM, there are several specified codes that will highly specify the site of the lipoma:
D17.0: Benign lipomatous neoplasm of skin and subcutaneous tissue of head, face, and neck D17.1: Benign lipomatous neoplasm of skin and subcutaneous tissue of trunk D17.2: Benign lipomatous neoplasm of skin and subcutaneous tissue of limb (including right arm, left arm, right leg, and left leg and based on laterality) D17.3: Benign lipomatous neoplasm of skin and subcutaneous tissue of other sites D17.4: Benign lipomatous neoplasm of intrathoracic organs D17.5: Benign lipomatous neoplasm of intra-abdominal organs D17.6: Benign lipomatous neoplasm of spermatic cord D17.71: Benign lipomatous neoplasm of kidney D17.72: Benign lipomatous neoplasm of other genitourinary organ D17.79: Benign lipomatous neoplasm of other sites (including peritoneum and retroperitoneum)
The last example of a misused unspecified code is 382.9, Otitis media, unspecified. When coding for ICD-10-CM, we will notice that the type and laterality of the otitis media is clearly documented:
H65.0: Acute serous otitis media (includes laterality codes for right, left, and bilateral as well as recurrent) H65.2: Chronic serous otitis media (includes laterality codes for right, left, and bilateral) H65.3: Chronic mucoid otitis media (includes laterality codes for right, left, and bilateral) H66.00: Acute suppurative otitis media without spontaneous rupture of eardrum (includes laterality codes for right, left and bilateral as well as recurrent) H66.01: Acute suppurative otitis media with spontaneous rupture of eardrum (includes laterality codes for right, left, and bilateral as well as recurrent) H66.1: Chronic tubotympanic suppurative otitis media (includes laterality codes for right, left, and bilateral) H66.2: Chronic atticontral suppurative otitis media (includes laterality codes for right, left, and bilateral as well as the use of an additional code for perforation of tympanic membrane)
In conclusion, the physicians must document the laterality, site, and the specification of acute versus chronic, versus acute recurrent when documenting several conditions within the ICD-10-CM. As you will see as we delve into the mystery that is ICD-10-CM, there is no longer the need (except for rare instances) that we will have to submit an unspecified code versus a more specified code.