Policy & Regulation News

Will Less Specific ICD-10 Codes Ruin Future Data Quality?

By Jacqueline DiChiara

- ICD-10 issues abound as the October transition date looms nearer. Of primary recent concern is that of coding specificity. Just as dialing only an isolated area code will not successfully connect you to a caller, a string of absent characters after the decimal within an ICD-10 code will only warrant an invalid code come October. Will invalid codes soon become a notable issue that will mar the future of healthcare's collective data quality?

ICD-10 codes

Coalition for ICD-10 expresses upcoming ICD-10 concerns

The Centers for Medicare & Medicaid Services (CMS) announced another “successful” ICD-10 Medicare Fee-For-Service (FFS) testing week in June. As HealthITAnalytics.com reported, according to CMS, 90 percent of over 13,000 nationwide test claims from 1,238 submitters were accepted. Most rejected claims stemmed from improperly developed test claims which CMS claims were separate to ICD-10. 

Regarding this recent news from CMS, the Coalition for ICD-10 (Coalition) voices several concerns and details anticipated problems that may arise come October. There is no evidence supporting the need for a “safe harbor” ICD-10 period, the Coalition says.

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  • The Coalition confirms particular interest in CMS’s statement stating dual processing of ICD-9 and ICD-10 codes will not be allowed on or after October 1. As RevCycleIntelligence.com reported, the Coalition stated an ICD-10 “grace period” will prove disastrous. The Coalition has formerly urged the healthcare industry to cease further ICD-10 delay initiatives and move forward with ICD-10 implementation. 

    “Many providers and payers, including Medicare, have already coded their systems to only allow ICD-10 codes beginning October 1, 2015. The scope of systems changes and testing needed to allow for dual processing would require significant resources and could not be accomplished by the October 1, 2015, implementation date,” states CMS.

    “Should CMS allow for dual processing, it would force all entities with which we share data, including our trading partners, to also allow for dual processing. In addition, having a mix of ICD-9 and ICD-10 codes in the same year would have major ramifications for CMS quality, demonstration, and risk adjustment programs,” CMS explains.

    Coalition for ICD-10 says non-specific codes are a non-issue

    According to the Coalition, “it is essential to understand that both ICD-9 and ICD-10 are structured so that there is always a ‘clinically accurate but less granular code’ available. Under ICD-9, Medicare has ALWAYS accepted ‘less specific’ codes, and providers are well-accustomed to the level of specificity required.”

    The Coalition adds that the level of specificity currently required under ICD-9 will essentially mirror the specificity implemented during the ICD-10 transition. “Every effort should be made to capture the most complete clinical documentation to support the most specific code,” the organization maintains.

    Says the Coalition, “it would be inappropriate and a violation of coding rules to require a level of specificity that is not documented in the medical record. Indeed, CMS has made it abundantly clear that it would be inappropriate to select a specific code that is not supported by the medical record documentation or to conduct medically unnecessary diagnostic testing in order to determine a more specific code.”

    The vaguely presented meaning of “subcode” in the ICD-TEN Act is “not clear,” says the Coalition, comparing dialing only an area code and not being able to effectively make a phone call to invalid ICD-10 coding issues where erroneous numbers following the decimal point will not render a code as valid.

    “All of the characters before and after the decimal are required to have a valid ICD-10 code and the characters after the decimal point are not analogous to CPT modifiers, which may or may not be appended to the base CPT code depending on the given situation,” the Coalition confirms. “Also, information provided in the characters after the decimal point is not limited to highly specific details such as laterality or anatomic site.”

    It is hopeful the utilization of less specific diagnosis codes will not negatively impact healthcare data’s collective quality levels come October.