ICD-10 has the potential to improve healthcare in America but along with all the new codes and the higher level of specificity it brings, ICD-10 retains one category that, if abused, could negate many of the accompanying advantages, or at the very least create a billing mess: the unspecified option.
“There’s a huge loophole. For almost every single code set there’s an unspecified code,” says Rhonda Buckholtz, vice president of business and member development at AAPC (American Academy of Professional Coders).
The unspecified field is not new to ICD-10. Indeed, it's a standard feature of a classification system and, as such, part of ICD-9, according to Sue Bowman, director of coding policy and compliance at AHIMA.
Given that many providers are behind recommended schedules for ICD-10, and HIPAA 5010 for that matter, there's a feeling in the industry that some providers may be tempted, if not ultimately forced, to relegate some claims to 'unspecified' rather than seek out the more accurate ICD-10 codes if they're more difficult to understand.
Dennis Winkler, director of technical program management at Blue Cross Blue Shield of Michigan explained why that poses a problem.
“So everybody’s compliant but what if 95 percent of all our claims come in as 'other' or 'unspecified' ICD-10 codes?” Winkler asks in this interview with ICD10Watch. “They get paid, life is good, but the benefits associated with this additional level of granularity, and the ability to get more finite as to what’s really going on in the doctor’s office or the hospital, you lose. So nothing breaks, but none of the benefits will materialize.”
Health plans are already starting to address this by instituting policies that they won't pay for an unspecified code when a more specified alternative exists, AAPC's Buckholtz says. And that's where chaos might enter in the form of rejected payments, the administrative burden of having to supply additional documentation to get a claim back, and the lost opportunity for improved healthcare that greater granularity can afford, notably more specific data for reporting on health outcomes and trends.
What's more, AHIMA's Bowman adds that “over-reliance on unspecified codes will result in poor healthcare data, as well as impact on initiatives that depend on both the quality of the coded data and the quality of the medical record documentation, such as provider profiling or value-based purchasing.”
If all this seems like little more than a distant possibility, then consider Buckholtz's experiences.
“I’m finding about 40 percent of the time, you’re unable to assign a specific ICD-10 code based off of current documentation,” Buckholtz explains. “For physicians to just default to the unspecified is doing a disservice to the physician and to the patient. The physician is not going to get paid and the patient isn't going to get treatment they need because the medical record doesn’t support the testing and procedure the patient needs.”
All that said, it's perhaps a bit early to tell whether providers will turn too heavily toward 'unspecified', but they would be wise to consider these consequences from the onset.
Tom Sullivan blogs regularly at ICD10Watch.