Coding to Highest Specificity ICD

Why it is important and how it affects
you as a physician.
Jeni Smith, CPC
Quality Report Suffers
 It
will not paint an accurate picture of the severity of the
 Severity
of illness is a measure of the patient's overall
health status reflected by the resources necessary for care
and the risk of morbidity and mortality
 “severity
of illness is understated 8%-15% of the time.
Mortality is understated 15%-25% of the time.” (For the
Record, page 11)
 Reporting
comorbidities and illness severity will help better
define quality of care and medical necessity for that care.
85% of Medicare RAC audit identified overpayments have
been directly related to coding, determination of medical
necessity and/or a need to enhance detailed
documentation gathered in support of submitted claims.
RAC took back over $900 Million from hospitals (Took 3 Mil.
from AGH)
More MCC, can lead to increased level of visit
Increases in morbidity, mortality, and length of stay will
not correlate with the documented severity of illness
which could lead to red flags
to ICD-10 System
ICD-10 offers more detailed information and the
ability to expand specificity
Greater specificity and clinical information,
which results in:
Improved ability to measure health care services
Increased sensitivity when refining grouping and
reimbursement methodologies
A code is invalid if it has not been coded to
the full number of digits required for that
 Provider
reports the full ICD-9-CM
 ICD-9
codes may have three to five digits
depending on their category.
 Each
digit provides important information about
the patient's condition.
ICD- D 9-CM Diagnosis
(Can be found on lab
Stage 1
Stage 2 (mild)
Stage 3 (moderate)
Stage 4 (severe)
Stage 5
End Stage Renal Disease
Chronic Kidney Disease,
250.13, uncontrolled type 1 diabetes with ketoacidosis.
Choosing the most specific code means coding only what you know
to be a fact.
The three-digit code (in this case, 250) represents the
diagnostic category.
The fourth digit identifies complications associated with
The fifth digit describes the type of diabetes and its level of
To correctly code an encounter with a patient who has uncontrolled
type 1 diabetes complicated by ketoacidosis, you should use all
five digits.
Patient, follow-up of benign essential
hypertension = 401.1 (The fourth digit
identifies the disease as benign and thus is the
most specific description of your patient's
However, patient also has benign
hypertensive heart disease, include a fifth
digit = 402.10 or 402.11 (depending on the
absence or presence, respectively, of congestive
heart failure)
You must always code to the highest number
of digits that best describe your patient's
 Physicians are legally responsible for the
codes selected and submitted
to payers.
 Coding to the highest specificity allows for
more accurate report of quality of care and
will prepare you for possible RAC audits and
the implementation of ICD-10-CM.
Heart Failure – Systolic or Diastolic
 COPD – Need to state acute exacerbation
 Sepsis – If code as 599.0, translates to UTI
-Need to state Sepsis due to UTI
 CVA – State with Residual or presenting symptoms
 Anemia – Chronic, Acute blood loss, iron
 Pneumonia – Which Bacteria
 DM – Need type and whether
 Morbid Obesity – Must state BMI, can increase
reimbursement by thousands (Already calculated
on MAR)

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