Coding insights: ICD-10 follow-up: Unspecified codes and modifiers

December 25, 2015

Coding and billing advice from the experts.

Q: As billing and coding manager for our group, I want to make sure that we are using ICD-10 codes correctly. How should I instruct our staff to use unspecified codes?

A: In both ICD-9 and ICD-10, it has been appropriate, and even necessary at times, to use signs/symptoms and unspecified codes. While you should report specific diagnosis codes when they are supported by the medical record documentation and clinical knowledge of the patient’s health condition, in some instances signs/symptoms or unspecified codes are the best choice to accurately reflect the encounter. You should code each healthcare encounter to the level of certainty known for that encounter.

My suggestion when gauging whether or not it is appropriate to code with more specificity is this: if you would need an additional test–which you normally wouldn’t perform because it’s not medically necessary to treat the condition–to gain the information needed for the more specific code, then code the unspecified ICD-10 code.

In other words, if the more specific test information would not change the way you would treat the patient’s condition, the unspecified code is appropriate.

Q: Can you please clarify whether or not the CPT or HCPCS codes change? Also, we use the modifiers for laterality. Will these change?

A: On October 1, 2015, ICD-10 replaced the ICD-9 code set used by providers for reporting diagnosis codes for Part B claims billed on the CMS-1500 claim form. Implementation of ICD-10 does not change the reporting of Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes, including CPT/HCPCS modifiers for physician services.

 

According to “ICD-10-CM Official Guidelines for Coding and Reporting” for fiscal year 2015, which can be found at 2015 ICD-10 Guidelines, some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.

If the side is not identified in the medical record, assign the code for the unspecified side. In addition, CMS has specified that, while ICD-10 codes have expanded detail, including specification of laterality for some conditions, providers will continue to follow CPT and CMS guidance in reporting CPT/HCPCS modifiers for laterality.

Q: Our software will not be upgraded to handle ICD-10 billing for a few months. How can we get our claims paid?

A: Medicare is offering the following claims submission alternatives. Each of these requires the provider to be able to code in ICD-10:

  • free billing software that can be downloaded at any time from every Medicare Administrative Contractor (MAC),

  • in about half of the MAC jurisdictions, Part B claims submission functionality on the MAC’s provider internet portal, or

  • submitting paper claims, if the Administrative Simplification Compliance Act waiver provisions are met.

 

Renee Dowling is a billing and coding consultant with VEI Consulting in Indianapolis, Indiana. Send your billing and coding questions to medec@advanstar.com.