Beware of the "Unspecified" Diagnosis Code

ICD-10 was introduced to the medical billing world in October, 2015. ICD-10 codes became key to the success of any medical billing platform, whether you bill yourself or outsource your billing almost immediately. The key difference when billing ICD-10 codes vs ICD-9 is that the ICD-10 codes begin with a letter, such as F or G. ICD-9 codes did not follow this format. 

The medical billing world was in some ways turned upside-down by ICD-10. When introduced, there were now 70,000 codes for a medical biller to know and understand! This was quite an increase over the 14,000 or so codes that medical billers needed to worry about with ICD-9. Nevertheless, we must adapt and ICD-10 is here to stay. 

In many ways, ICD-10 is an important introduction into the world of insurance billing. The codes provide more specificity than ICD-9, and allow a healthcare provider to properly define the diagnosis of a patient. At the same time, certain codes were designated as "unbillable" because they were deemed not specific enough. For example, if you are a behavioral health provider (a field that GreenpointMed specializes in), and you tried to use the DX code F33, Major Depressive Disorder, recurrent, your claim would be rejected. Here's an important distinction: rejection vs denial. A rejection is a claim that did not make it to the insurer for processing, and bad DX codes are a common reason why. Other reasons a claim would be rejected is a bad member ID or bad DOB entered on the claim. A denial on the other hand is a claim that was processed by the insurer where payment was refused. Name your reason why a claim is denied; often it can be as simple as human error on the part of the insurer (nobody is perfect).

Medicare has developed a comprehensive Coverage Database which analyzes all claims submitted at a local level through a Local Coverage Determination (LCD) database. One denial we are beginning to see as a medical billing service that processes thousand's of claims per month are claims with billable DX codes. What do I mean? If your code ends with a ".9" there is a  chance that it will be denied. The reason: codes ending in ".9" are by definition unspecified. Medicare does not like this, and so they are being denied  as a result. Looking at two examples, F80.9, Developmental disorder of speech and language, unspecified; F33.9, major depressive disorder, recurrent, unspecified.

Even if you are not a Medicare provider, this still could affect you. Commercial insurers typically follow Medicare guidelines on reimbursement, coding and other policies. If Medicare is providing guidance on a specific policy, such as which DX code is acceptable and which is not, there is a chance that your commercial insurer like UnitedHealthcare, Aetna or the Blues will follow. Medicare is the leader, and the commercials are the followers. 

These are not hard and fast rules, and there will be exceptions (like everything in billing insurance). At GreenpointMed, we have a great search engine that is available to our clients which helps define billable vs. non-billable codes. The difference between submitting a billable code can drastically speed up your reimbursement and lead to fewer headaches for you (and your biller). 

Bottom line: avoid the unspecified diagnosis codes where you can.

Just for fun, let's take a deep dive into some other ICD-10 codes that exist which you may not be aware of:

  • W56.02XA: Struck by dolphin, initial encounter: (was there a second or even third encounter?). If you have ever swam with a dolphin or seen one at an aquarium, it definitely could hurt if you were to get struck by a dolphin. However if I were lost at sea, there is no mammal I would rather find myself with then the friendly porpoise. *We believe we have identified what this type of diagnosis might look like. Please visit our Twitter page, https://twitter.com/Greenpoint_Med, to evaluate.
  • V91.07XA: Burn due to water-skis on fire, initial encounter: First, I hope there is no subsequent encounter (there actually is no billable code for second encounter), and wouldn't a possible remedy for this affliction be to jump into the water?

I don't mean to make light of anybody's plight. However this should give you an idea of the extent of codes that are available under ICD-10. And if you were asking, yes, these codes are technically billable.