2016 – The Year of The Specific

We are starting off the new year with a guest post by Stanley Nachimson, Principal of Nachimson Advisors LLC



So we survived 2015 – the year of ICD-10 implementation. Congratulations on a job well done, but it is just the start.  Let’s look at 2016 and consider it the Year of the Specific.  Specificity should be the goal for providers, in thought and action.  Focus must be on getting the specific information about the patient, getting the specificity documented, and then using that specific documentation to select the most specific (and most accurate) ICD-10 code to place on the patient’s record and the bill to the insurance company.


We do know that ICD-10 contains non-specific and “other” codes; these are legitimate codes in the appropriate situation.   But the national standards; the official ICD-10 coding guidelines, require that coding be done to the greatest specificity using the information available to the provider. If you know it, use it.


Why is this specificity important for providers? First, it will help get your claims paid faster.  While health plans talk of some flexibility at first, there will be more edits and more specific requirements as we move through 2016.  Best to prepare for them now.  Secondly, you want to be prepared for audits and questions from health plans on a post pay basis. Having the correctly specified documentation will allow you to pass those audits with flying colors and avoid giving money back.  And thirdly, quality measures based on diagnoses are used to rate physicians and other providers. You want those measure to accurately reflect the acuity of your patient population.


And from a longer term view, the ICD-10 codes will be used for public health, research, and best practice development. Not being a medical professional (and frankly being a bit squeamish about medical details), I like to use the sports injury codes as an example.  Under ICD-10, there are codes for sports injuries that specify the sport and the way the injury occurred (e.g. struck by a thrown baseball).  While not necessary to treat the patient, certainly the cause of injury information is quite useful to measure the rate of injuries in various sports, and to use that information to help make sports safer to play especially for our kids.


That specificity extends to the causes of infections, the types of fractures, the trimester of pregnancy issues, and other medical conditions.   We need this information to be accurate so that the conclusions we draw reflect what is actually happening in the population and lead us to the right solutions.

So make it a point to be specific.  It is a benefit for the patient, the provider, and the system as a whole. 




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