ICD-10 leaves ICD-9 loophole in place

by Anne Zieger on November 8, 2010

Without a doubt, implementing ICD-10 will force providers to make some big changes.  Still, the new system includes a big loophole familiar to ICD-9 users — one which should prove a temptation to do some lazy documentation and coding, according to a report in HealthcareITNews.

The loophole, known to coding whizzes as “the unspecified option,” is a field allowing providers to relegate some claims to this catch-all category.  While providers can code items as “unspecified” under ICD-9, some observers think there may be a big spike in the use of unspecified codes.

Experts who spoke to the magazine note that it will be especially tempting for providers to use unspecified categories as tough new ICD-10 and HIPAA 5010 challenges roll in.  After all, providers have been on a breakneck schedule working to comply with ICD-10 requirements by the appropriate deadlines.

And of course, there’s the small matter of needing to implement electronic medical records, integrate them with other systems, train staff to use them and more.  At least some experts believe that practices won’t be successful at running a medical home without an EMR in place, so pile on one more pressure.

We’re talking one heck of a complicated dance here.

That being said, health plans hope to put a quick stop to the excessive use of “unspecifieds.”  Some plans are already developing policies which state that they won’t pay for a claim relying on an unspecified code if a more specific alternative exists, according to HealthcareIT News.

If enough health plans stand by such rules, providers may face a huge backlog of rejected payments and resubmitting claims with new documentation, something they hardly need when they’re already struggling to learn the new system.

The only cure to all of this seems to be better documentation which allows doctors to avoid unspecified codes as often as possible.  Right now, about 40 percent of the time it’s impossible to assign specific ICD-10 codes given the documentation available, according to one coding expert.

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{ 2 comments… read them below or add one }

Mark Montgomery November 8, 2010 at 4:05 pm

Good focus Anne

This is yet another example of the garbage-in garbage-out problem that structured data systems can overcome. If accurate information is organized correctly from inception, then the embedded data on patient, physician, disease, drug, therapy, payer, etc. can be automated.

You may recall the recent press reports about the effort in India to create identities of the entire population with biometrics, so that electronic health records among other issues can be automated much more efficiently and securely.

The effort started as a volunteer group before attracting government funding– a grass roots effort at very low costs upfront that can save a fortune once up and running.

The U.S. is advanced in some areas, but way behind in others. — MM

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Anne Zieger November 8, 2010 at 8:03 pm

Mark, thanks for your comments! As I see it, this is just another reminder that simply demanding subjects produce richer data is doomed to failure. You have to provide them with tangible, short-term rewards. Even high-level benefits like “might do better in a medical home situation” won’t do the trick.

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