We have been receiving a number of calls and emails and coding questions regarding the “discontinued” use of all unspecified codes after October 1^st, 2016.

Many entities are incorrectly or inaccurately reporting that CMS and commercial carriers will no longer accept any unspecified codes after October 1, 2016. We have also had clients attend webinars where the lecturer told attendees not to use any ICD-10 codes ending in 0 or 9.

Here is some information to clarify any confusion and set you along a straighter path.

First, the information is only partially true, but it’s not an absolute rule. It appears that the authors of these articles or presenters giving these webinars clearly don't understand ICD-10... and are frankly offering erroneous and bad advice.

Here is the correct information...

CMS and commercial carriers want you to avoid the use of unspecified codes, if at all possible. But sometimes this isn’t possible and sometimes the use of an unspecified code is perfectly acceptable and payable.

First, CMS states that the use of unspecified codes is acceptable when, based on all clinical knowledge at the time of the encounter, the provider can't specify an exact condition.

Here is an ICD-10 Myths and Facts Bulletin (See page 2)

https://www.cms.gov/medicare/coding/icd10/downloads/icd-10mythsandfacts.Pdf

“In both ICD-9-CM and ICD-10-CM, sign/symptom and unspecified codes have acceptable, even necessary, uses. While you should report specific diagnosis codes when they are supported by available 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 health care encounter. You should code each health care encounter to the level of certainty known for that encounter.

If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code (for example, a diagnosis of pneumonia has been determined but the specific type has not been determined). In fact, you should report unspecified codes when such codes most accurately reflect what is known about the patient’s condition at the time of that particular encounter. It is inappropriate to select a specific code that is not supported by the medical record documentation or to conduct medically unnecessary diagnostic testing to determine a more specific code.

CMS also released some clarification FAQs on the use of unspecified codes and the end of the grace period.

https://www.cms.gov/Medicare/Coding/ICD10/Clarifying-Questions-and-Answers-Related-to-the-July-6-2015-CMS-AMA-Joint-Announcement.pdf

See questions 27

Question 27: (new 08/18/2016) Will unspecified codes be allowed once ICD-10 flexibilities expire?

Answer 27: Yes. In ICD-10-CM, unspecified codes have acceptable, even necessary, uses. Information about unspecified codes, including an MLN Matters article and videos, can be found on the CMS website. While you should report specific diagnosis codes when they are supported by the available 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 health care encounter. You should code each health care encounter to the level of certainty known for that encounter. When sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code (for example, a diagnosis of pneumonia has been determined but the specific type has not been determined).

What they are really trying to say…

The first issue centers around site-specific ICD-10 codes. If there are site-specific ICD-10 code choices (e.g., trunk, face, left lower extremity, etc.) those codes should be used instead of an unspecified body site. In other words, you don't want to use codes for Basal Cell Carcinoma, unspecified parts of face (C44.310), when you should be using BCC of nose (C44.311) or BCC other parts of face (C44.319).

The same is true for ICD-10 codes where left vs. right, or upper vs. lower, choice exists. Again, don’t default to "unspecified" codes when site-specific or laterality-specific choices exist. Dermatology is a visual specialty and there is no excuse not to document where, and left vs. right, or upper or lower, etc.

Sometimes, based on what is known at the time of the encounter the provider has to use an unspecified code because not enough clinical information is known. For example, the patient may have dermatitis, but the provider cannot determine a cause. The use of an unspecified dermatitis code is appropriate here.

Not all codes ending in ‘0’ or ‘9’ are unspecified

It is not true that all unspecified codes end in a ‘0’ or ‘9’.

In the previous example, Basal Cell Carcinoma of “other parts of face” is C44.319, and happens to end in a '9'. C44.319 is a specific payable ICD-10 code.

Here’s another example. You don't want to use Allergic Dermatitis of unspecified eyelid (when you should know to code either the upper or lower, or left vs. right).

Let’s look at Actinic Keratoses. The ICD-10 code is L57.0. This code happens to end in a ‘0’. It’s a specific payable ICD-10 code for CPT codes 17000/17003.

Here are some other examples of ‘specific’ ICD-10 codes ending in ‘0’ or ‘9’

L10.89 - Pemphigus, other

L60.0 - Ingrown Nail

C4A.0 - Merkel Cell Carcinoma of the Lip

Not all unspecified codes end in ‘0’ or ‘9’

Look at these ICD-10 codes. They are ‘unspecified’ but don’t end in a ‘0’ or a ‘9’!

L25.3 - Unspecified contact dermatitis due to other chemical products

H61.001 - Unspecified perichondritis of right external ear

D49.2 - Neoplasm of unspecified behavior of bone, soft tissue, and skin

The use of “other” versus “unspecified”

Often, you will see that an ICD-10 code series offers “other” as one of the code choices. If the condition you are coding doesn’t fall into one of the specific ICD-10 codes listed, and an ‘other’ code exists, default to the ‘other’ code instead of the unspecified code.

Example 1 - If the patient has psoriasis, and it’s not one of the types listed in L40.0-L40.5, default to ‘other psoriasis’ (L40.8) instead of psoriasis, unspecified (L40.9).

L40.0 - Psoriasis vulgaris

L40.1 - Generalized pustular psoriasis

L40.2 - Acrodermatitis continua

L40.3 - Pustulosis palmaris et plantaris

L40.4 - Guttate psoriasis

L40.5 - Arthropathic psoriasis

L40.8* - Other psoriasis

L40.9 - Psoriasis, unspecified

Example 2 - Basal cell carcinoma of the cheek. Here are your choices…

C44.310 - Basal cell carcinoma of skin of unspecified parts of face

C44.311 - Basal cell carcinoma of skin of nose

C44.319 - Basal cell carcinoma of skin of other parts of face

It’s not the nose, so choose “other parts of face” (C44.319). Don’t use the unspecified code!

Check the carrier’s LCDs or medical payment policies

Lastly, check your Medicare LCDs or carrier medical policies. These will usually list the covered ICD-10 codes for certain CPT codes where an LCD or medical policy exists.

Here is the “Removal of Benign Skin lesions” LCD for Michigan Medicare for CPT code 17110. You will see reference to B07.9 (Viral Wart unspecified) as a covered ICD-10 code.

http://www.dermcoder.com/lcd.aspx?lcdid=35498&code=17110

And here is an Aetna Phototherapy and Photochemotherapy (PUVA) for Skin Conditions policy showing unspecified contact dermatitis, unspecified cause as a covered ICD-10 code for UVA/UVB light therapy.

http://www.aetna.com/cpb/medical/data/200_299/0205.html

Need additional ICD-10 help?

We highly recommend you purchase our 2017 ICD-10 for Dermatology, which includes a 1-hour derm-specific webinar, an update for all of the changes affecting dermatology, plus great dermatology-specific training and examples. I also go over the 50 most common dermatology questions we've received and ICD-10 pitfalls. It's been our best seller the past 3 years and we just updated it for all the changes effective October 1st 2016 and for next year!

http://www.ellzeycodingsolutions.com/2017-ICD-10-for-Dermatology-ICD-10-Guide-and-Prese-p/2017-icd10-pkg.htm