Medicare review contractors won’t deny ICD-10 claims billed by physicians or other practitioners under the Part B physician fee schedule during either automated medical reviews or complex medical record reviews based solely on the specificity of the ICD-10 diagnosis code, as long as the physician/practitioner uses a valid code from the right family of codes.

The Centers for Medicare & Medicaid Services (CMS) grace period for ICD-10 specificity will extend for 12 months following the October 1 implementation date, and applies to Medicare Administrative Contractors, the Recovery Auditors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor.1

However, because not all commercial insurers are following CMS’ lead, it’s important for providers to double-check to be sure they know where payers stand regarding code specificity and denials. Here’s a brief run-down of the policies outlined by several major insurers:

  • Aetna: The company stated that for dates of service of Oct. 1, 2015, and after, providers “should use ICD-10 codes in all transactions where ICD coding is required. All policies that we apply during the claims payment process won’t change, other than a conversion to the ICD-10 code set.”2

  • Anthem: Anthem willfollow CMS guidance and not reject Medicare Part B Fee-for-Service Claims that are coded with an ICD-10 code within the correct family even if the correct level of specificity is not used.3

  • Cigna: In a frequently asked questions document from September 2015, Cigna stated that “When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it will be acceptable to report the appropriate `unspecified’ code. (e.g., a diagnosis of pneumonia has been determined, but not the specified type.)”4

  • Humana: The company states that “Humana will follow current CMS guidelines. Per CMS, each health care encounter should be coded to the level of certainty known for that encounter. Clinicians 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.”5

As of Oct. 26, 2015, no information was available on the United Healthcare website to indicate whether the company was following CMS guidance on specificity denials or not.

In addition to checking with commercial carriers, state Medicaid policies regarding lack of ICD-10 specificity should also be reviewed and closely monitored. The state program in Georgia, for example, will not provide a grace period for unspecified codes. The following comes from the program’s website:6

Q: Could you explain the Medicaid policy on unspecified codes and the requirements for ICD-10 effective October 1, 2015?

A: NOS, or “not otherwise specified” codes will be denied as there is not enough clinical documentation to determine the diagnosis. NEC codes, or “not elsewhere classified” will be supported as this means there is not an appropriate or an existing ICD-10 code to support it. Clinical justification is required if providers uses an NEC code. The physician is required to bill at the lowest specificity or diagnosis code level selecting the most appropriate specified code. The physician’s documentation must be clear, complete and concise to support the code billed. Example: A patient is seen for injury to the right and/or left eye, but the provider bills using a diagnosis code of “other” as an unspecified code. Unless the provider has documentation that there is a third eye, then this claim with an unspecified diagnosis code of “other” would be denied.

“Because policies differ between carriers, physicians need to make sure that they’re aware of what each insurance company is doing regarding coding specificity,” said Lisa Schroeder, compliance director for web2pro Business Performance Services (web2pro). “Failure to do so could result in unexpected denials and potential cash flow problems.”

1 “ (PDF, 199 KB),” Centers for Medicare & Medicaid Services,” July 9, 2015
2 “ (PDF, 97 KB),” Aetna, August 2015
3 “,” Anthem Blue Cross, July 2015
4 “ (PDF, 210 KB),” Cigna, September 2015
5 “,” Humana, 2015
6 “ (PDF, 109 KB),” Georgia Department of Community Health, Sept. 9, 2015


About the author

web2pro Business Performance Services offers services and consulting to help hospitals, health systems, and physician practices improve business performance, boost margins and transition successfully to value-based care.