Oct. 1 has come and gone — soon we may be seeing an increase in claims rejections from the Centers for Medicare and Medicaid Services (CMS), and other payers due to the lack of specificity of diagnoses. Although the occasional usage of unspecified ICD-10-CM codes may be appropriate, the use of unspecified codes should be the exception, not the rule.
Medical practices and hospitals could fail if physicians do not evolve with the changing reimbursement landscape. There are more potential effects than just financial for services actually provided. The CMS "Five Star Ratings" for physician quality may be affected. For example: The provider is not a one star physician because he/she delivered bad care. He/she is a one star physician because his/her documentation does not reflect the severity of the patient’s illness.
Example 1: If clinical indicators are present, documentation of “Acute (hypoxic or hypercapnic) respiratory failure” instead of “Shortness of breath” will be more accurately reflected in the case mix index (CMI), and also meet compliance with specificity documentation.
Example 2: “Severe persistent asthma” instead of “Asthma” will more accurately reflect the CMI and also meet compliance with specificity documentation.
Example 3: “Bladder infection, kidney infection, or Urethra infection” instead of “UTI” will more accurately reflect the CMI and also meet compliance with specificity documentation.
Further specificity will also REDUCE physician queries thus leaving more time to provide quality care.
Additional specificity information can be found on the ICD-10 and CMS websites.