ICD-10 clarification from CMS

Here is the link to the CMS FAQ document about specificity and ICD-10.  They clarified that when they said “family” they meant “category” because ICD-10 doesn’t use the term family in coding. (I theorized that if the code was in a page or two of the right code it would be okay, but that’s not what they meant, was it?)  Just a reminder, we use diagnosis coding for two reasons on a claim form.  The first is to establish the medical necessity to get a claim paid.  The second is to tell the payer how sick the patient is, and the acuity of our entire population of patients.  This is important for risk based contracts and ACOs. Even an unspecified code establishes the medical necessity for an office visit, but that doesn’t mean you should use it.  You should report the condition you are treating specifically.  And, if the service you are performing has a Medicare LCD or NCD, or a private payer coverage policy, you will need a specific, covered indication.

As for private payers, who knows?

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