OMED 2016

Are unspecified ICD-10 codes setting your practice up for a Titanic scenario?

On Oct. 1, 2016, CMS will start denying claims that use unspecified ICD-10 codes. Here’s how to avoid the iceberg of revenue disruption.


When the ICD-10 code set went into effect last Oct. 1, the Centers for Medicare and Medicaid Services (CMS) gave doctors a grace period of sorts: CMS wouldn’t deny claims for lack of specificity until Oct. 1, 2016. Given ICD-10’s total of 68,000 diagnostic codes, that was welcome news at the time, but Matthew Menendez says it may have lulled physicians into a false sense of security.

“Delaying the denial of unspecified codes has enabled poor workflows to be successful,” said Menendez, the vice president of practice management company White Plume Technologies. “This is the part of the iceberg that’s below the water—it seems like it’s not a problem, but it’s out there waiting for us.”

Menendez and family medicine physician Joseph Mazzola, DO, shared tips on what physicians can do to minimize claim denials as part of the American College of Osteopathic Family Physicians’ OMED 2016 program on Monday. Physicians who continue using unspecified codes after Oct. 1, 2016, risk denied claims and disruptions to their practice revenue cycles.

The issue is especially relevant to physicians whose payment depends on the revenue they generate, Dr. Mazzola pointed out. “As denials come in, if you’re up for contract renewal, I may have to say, ‘Doctor, you’re doing fine with visit numbers, but your revenue is down,'” said Dr. Mazzola, who oversees more than 100 physicians in his role as chief medical officer for Blue Ridge HealthCare in Morganton, North Carolina.

Another disadvantage of unspecified codes is that they fail to document patients’ complexity. “Physicians who use lots of unspecified codes might start hearing, ‘Why can’t you see 25 or 28 patients a day? Why not put in a midlevel clinician to do this work?'” Dr. Mazzola noted. Unspecified codes do often represent a missed opportunity, Menendez agreed: “Many physicians’ documentation supports a more specific code; they’re just not using it.”

How to get started

Although physicians should work to reduce unspecified codes, Menendez noted, the goal is not to eliminate them altogether. “You’re not aiming to get your unspecified codes down to zero—there are times using them is absolutely appropriate, such as when you’re waiting for lab results or it’s not clear what’s causing a patient’s fever,” he explained.

To reduce use of unspecified codes, Dr. Mazzola and Menendez recommend these steps:

  • Analyze claims from the last six months to find out what percentage use unspecified codes.
  • Pinpoint the top 10 or 15 unspecified codes that appear most frequently in your claims.
  • Find more specific alternatives for your top unspecified codes. For example, there are six ICD-10 codes for hyperlipidemia that could be used in place of code E78.5—Hyperlipidemia, unspecified.
    • Although the process might sound daunting, physicians can make a significant impact by focusing first on their most frequently used unspecified codes. “Your practice’s risk come October 1 really depends on how much specificity you’re coding with today and how much you’re willing to improve,” Menendez said. “It can be challenging to find a balance between using more specific codes without crushing physician productivity, but getting the right code the first time you submit a claim will really improve revenue efficiency.”

One comment

  1. Pingback: HP 212C - Unspecified Codes Discussion - University of Arkansas -

Leave a comment Please see our comment policy