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The Centers for Medicare & Medicaid Services (CMS), through its Medicare Learn Network (MLN), recently provided a presentation titled “ICD-10 Basics.” This was a great review for those of us entrenched in Wonderland, with stars in our eyes as we wish upon the implementation of ICD-10 to soon be over so we can get back to some semblance of a work routine.


Hidden gems often are discovered when we least expect it, and today a beautiful upside-down rainbow burst through my computer monitor when I heard and read slides 49-50 (see attached file). It was truth shinning above and pointing to those troubling unspecified codes.

Now we finally have it: there will be a place for unspecified diagnosis codes. However, guidance has been issued as to their selection.

As we move forward toward ICD-10, look at the five points below and begin to educate your providers on the use of unspecified codes.  Monitor the use of selected unspecified diagnosis codes by specialty and provide education regarding the appropriateness of using them. You eventually should realize a decrease in the selection of unspecified codes.

Fairy tale questions not discussed were related to reimbursement, such as “would the reimbursement be less or the same?” Obtaining answers will be an ongoing process based on accepted claim submission of an unspecified diagnosis code and a third-party payer. We will need to be vigilant in monitoring documentation supporting unspecified diagnosis codes and the accuracy of the diagnosis codes selected to mitigate any negative patterns.

According to the presentation speakers affiliated with the cooperating parties (the American Hospital Association, or AHA, the American Health Information Management Association, or AHIMA, the Centers for Medicare & Medicaid Services, or CMS, and the National Center for Health Statistics, or NCHS), the following statements were developed to clarify industry misconceptions regarding unspecified codes:

  • Each healthcare encounter should be coded to the level of certainty known for that encounter.
  • Unspecified diagnosis codes should need to be selected less often due to greater number of code choices in ICD-10-CM.
  • Unspecified diagnosis codes should be reported when they most accurately reflect what is known about the patient’s condition at the time of that particular encounter.
  • When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate “unspecified” diagnosis code.
  • It would be inappropriate to select a specific diagnosis code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.

Rainbows create a beautiful feeling of peacefulness as we witness their bright colors right in front of our eyes. With this one small tidbit of information, we can educate our providers and peers incrementally on improving clinical documentation to magically remove misconceptions.


About the Author

Gretchen Dixon, MBA, RN, is a consultant at Hayes Management Consulting. She is a Certified Healthcare Compliance Officer, Certified Coding Specialist and internal auditor with more than 20 years of experience in the healthcare industry with an emphasis on clinical documentation improvement, compliance, revenue cycle and coding.

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CMS MLN PowerPoint presentation http://www.cms.gov/Medicare/Coding/ICD10/CMS-Sponsored-ICD-10-Teleconferences.html


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