By Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC

President of Edelberg Compliance Associates, Baton Rouge, LA

Ms. Edelberg reports no financial relationships relevant to this field of study.

Oct. 1 marked the end of the one-year period of “flexibility” for ICD-10 reporting of unspecified codes. For the past 12 months, after ICD-10 implementation, Medicare review contractors were not denying Part B physician or other practitioner claims through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code. This assumed that the physician/practitioner used a valid code from the right family of codes.

Medicare review contractors include Medicare administrative contractors, recovery auditors, zone program integrity contractors, and supplemental medical review contractors — all responsible for auditing provider claims. No change would be made regarding the coding specificity required by the national coverage decisions (NCDs) and local coverage decisions (LCDs). NCDs and LCDs contain the reasonable and necessary conditions of Medicare coverage. In addition, there has been a rise in commercial insurers using similar guidelines and policies. For example, Humana lists provider payment integrity policies to support many of their coverage decisions when auditing provider claims.

Providers are expected to code to the highest level of specificity documented. The flexibility provided the first year after implementation of ICD-10 pertained solely for the purpose of contractors performing medical reviews. Thus, providers were given the grace period before audits began. Contractors were not expected to deny claims solely for the specificity of the ICD-10 code. However, if any claims were selected for medical review, the conditions identified as “unspecified” might fail to meet payment criteria under NCD or LCD policies.

Unspecified codes still are listed in ICD-10 2017 and are to be used when information in the medical record is insufficient to assign a more specific code. But that shouldn’t be the catch-all for problems seen in the ED that are not documented appropriately. For example, acute pneumonia with unspecified organism (J18.9) is an unspecified code and is billed commonly in the ED as the type of pneumonia undetermined at the time of treatment. It is appropriate to assign this code if no other information is available.

An acute exacerbation of asthma is another common problem managed in the ED. For asthma, the type often is unspecified in the provider documentation, and acute exacerbation generally is the default code. J45.901 defines unspecified asthma with acute exacerbation, J45.902 defines unspecified asthma with status asthmaticus, and J45.909 describes unspecified asthma, uncomplicated, or asthma not otherwise specified. Each of these codes falls into the “unspecified” category. However, with documentation of more specific conditions, such as simple persistent asthma with acute exacerbation (J45.31), moderate persistent asthma with acute exacerbation (J45.41), or severe persistent asthma with acute exacerbation (J45.51), the terms mild, moderate, and persistent require documentation consistent with the definitions below:

Mild Persistent

  • Symptoms: More than two days per week
  • Nighttime Awakenings: three to four times per month
  • Rescue Inhaler Use: More than two days per week, but not daily
  • Interference with Normal Activity: Minor limitation
  • Lung function: FEV1 greater than 80% predicted

Moderate Persistent

  • Symptoms: Daily
  • Nighttime Awakenings: More than once per week, but not nightly
  • Rescue Inhaler Use: Daily
  • Interference with Normal Activity: Some limitation
  • Lung function: FEV1 60-80% predicted

Severe Persistent

  • Symptoms: Throughout the day
  • Nighttime Awakenings: Nightly
  • Rescue Inhaler Use: Several times per day
  • Interference with Normal Activity: Extremely limited
  • Lung function: FEV1 less than 60% predicted

When reporting an ICD-10-CM category J45 code, additional codes are required to specify the following as applicable:

  • Exposure to environmental tobacco smoke (Z77.22)
  • Exposure to tobacco smoke in the perinatal period (P96.81)
  • History of tobacco use (Z87.891)
  • Occupational exposure to environmental tobacco smoke (Z57.31)
  • Tobacco dependence (F17)
  • Tobacco use (Z72.0)

These are just a few of the nuances of ICD-10 that pertain to services provided in the ED. With the conclusion of the grace period on Oct. 1, ED providers should document as much specific information about conditions managed in the ED as possible to avoid future audits on unspecified conditions. Never has specificity been more important for support of ED claims. We need to remember that our hospitals use the same documentation to support the facility billing, and hospitals can expect to see additional audits on their claims as well. Documentation supports the diagnosis-related groups as well, so it is important to know what claims are being denied when patients are admitted through the ED.

Work with your health information management and revenue cycle departments to identify ED claims that payers select for audit. Recognize where documentation could improve to avoid audits for professional and technical fees and share that information with other providers in the ED. Although prospective attention to documentation is the best policy, working with denials and claim audits is an effective way to identify documentation issues that prevent full payment for ED services. Additionally, the resources necessary to resolve claim disputes and manage audits is extraordinary, so the best policy is to avoid audits at all costs by documenting the specifics of each case managed in the ED.