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Georgia Medicaid Rejecting ICD-10 Claims using "Unspecified" Coding

The relative quiet that was the ICD-10 transition was disturbed this week by Georgia Medicaid, which is reportedly rejecting claims with unspecified diagnoses across the board.

PCC’s practices in Georgia have experienced rejections dealing with the “unspecified” code, and this is being met with consternation among physicians and billers who say their Medicaid reps have yet to give a substantive answer for the denials.

We, at PCC, are equally as non-plussed, as CMS has said it would accept all unspecified diagnoses.

When reached by one of our clients, a Medicaid representative said “any claim with an unspecific diagnosis listed on the claim would be rejected.”

This runs counter to what the American Health Information Management Association (AHIMA) explains in its “Clarification on the Use of External Cause and Unspecified Codes in ICD-10,” which reads:

Sign/Symptom/Unspecified Codes

In both ICD-9-CM and ICD-10-CM, sign/symptom and “unspecified” codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter.

If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). In fact, unspecified codes should be reported when they are the codes that most accurately reflects what is known about the patient’s condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.

Officially, there are four state Medicaid programs (California, Louisiana, Maryland and Montana) that say they are not ready for ICD-10 and have been cross-walking incoming ICD-10 claims and matching them to ICD-9 codes to prevent problems.

Georgia is not on the list, but it appears it should be.

Don’t Go It Alone

Meanwhile, we urge any practice experiencing this issue with Georgia Medicaid to contact Lou Terranova, manager of the AAP Private Payer Advocacy initiative, at lterranova@aap.org. Terranova assists AAP members and staff in dealing with payer issues.

4 replies
  1. Nancy Parizo says:

    As the GA MCD claims come in, we are finding very few denials for appropriate unspecified codes. What they are denying is the unspecified codes associated with conditions that require the much touted laterality, type, and sequela. They will accept an unspecified code for fever, unsp (R05.9) and pneumonia, unspecified organism (J18.9), and others. What they won’t accept is those codes that have numerous choices for more specificity such as otitis media/externa, asthma, conjuctivitis, etc. I suggest using the 323 page list of unacceptable codes that is posted in the mmis portal and can be downloaded for use when you post or scrub your claims. You can easily search by code or description and it takes no time to confirm whether or not the code will pay. Although a little inconvenient, it pays off in a quick payment of a clean claim.

  2. Jill says:

    Nancy, thank you very much for this clarification! Your expertise as a billing specialist is most welcome.

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