Potential Impacts of new Edit 20 for Inpatient Claims

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.