The list of unspecified diagnosis codes subject to the new edit will require targeted training for your billing staff to avoid reimbursement issues and provide a platform for improving CDI.
It is essential to perform a pulse check on the number of unspecified codes currently used in your organization to submit inpatient and long-term care claims. On Oct. 21, MLN Matters provided updates to the Medicare Code Editor (MCE), which includes a new edit, R11059CP, for unspecified codes. This edit will directly impact inpatient discharges occurring as of April 1, 2022.
Codes used to report Complications or Comorbidities (CCs) or Major Complications or Comorbidities (MCCs) are the targets of the new edit. The use of unspecified codes for these selected conditions will trigger a payment denial. It is important to understand the impact for an organization and the required focus for educating coders, clinical documentation integrity (CDI), physicians, and billing personnel.
This edit requires a code of greater specificity in order to initiate payment of a claim. It is the organization’s responsibility to ensure that documentation supports the opportunity to present a specific code. It is also important to note that an MCE edit is part of the Inpatient Prospective Payment System (IPPS), which is updated biannually, with the bulk of the updates implemented in October. This is not to be confused with the Medicare Outpatient Code Editor, which is part of the Outpatient Prospective Payment System (OPPS) implemented in January of each year. As with most inpatient and outpatient edits, these are updated within an encoder before the anticipated go-live date. Fortunately, this edit will alert coders or CDI staff that a code of greater specificity is required. However, the solution to the edit may not be as straightforward. The ability to provide a code of greater specificity must be documented in the medical record.
Having a clear understanding of the current volume of unspecified codes included in target codes selected to be subject to an edit will provide management the ability to safeguard against unnecessary denials. The code range is outlined in the 2022 fiscal year (FY) Inpatient Prospective Payment System Final Rule, as well as the LTAC Prospective Payment System for the 2022 FY. A complete list of codes impacted by this edit can be found in Table 6P.3a (Medicare Code Editor Unspecified Codes List). An example of a few of these codes is chronic embolism and thrombosis of unspecified femoral vein, pathological fracture, unspecified ulna and radius, initial encounter for fracture; and major laceration of unspecified external jugular vein, initial encounter. Most of the targeted codes are related to laterality.
Each organization should run an occurrence report determining the frequency of unspecified codes reported annually. This will allow management to focus their efforts on evaluating the need for coder training, CDI improvement, and physician service line training. In other words, unspecified codes could be arising due to a coder error or lack of specific documentation.
The Medicare Administrative Contractor (MAC) has the ability to bypass this edit if the appropriate communication is noted in the remarks field on the claim, informing Medicare that the necessary information is not available or the documentation in the medical record reflects that the physician is clinically unable to decide the laterality because of the nature of the disease or condition. Please note that there is a specific procedure to follow when documenting in the remarks field – this information is located in Change Request R11059CP, along with additional information pertaining to this edit.
Before the onset of ICD-10-CM, organizations placed a heavy emphasis on the need for specific documentation related to laterally to minimize the use of unspecified codes. The occurrence of unspecified codes should be few and far between. However, with the increasing rise in inpatient denials and already burdened billing, coding, and CDI staff, organizations must be proactive in evaluating and implementing the necessary changes needed prior to April 1, 2022.
Programming Note: Listen to Susan Gatehouse report this story live during Talk Ten Tuesdays today at 10 Eastern.
Coding in the post-acute care world has taken on a new significance in the past five years. For those of us who are coders, this
External audit volume more than doubled in 2024 over 2023 while total at-risk dollars increased fivefold to $11.2 million, impacting healthcare provider organizations’ cash flow
Please log in to your account to comment on this article.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.
Copyright © 2024 ICD10monitor. Powered by MedLearn Media.
Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more
Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!
