305.996 Unknown Diagnosis Coding Under ICD-10
The Medical Society for the State of New York (MSSNY) will ask the Centers for Medicare and Medicaid Services (CMS) to enforce Unknown Diagnosis Coding and ICD-10 Policy with private insurers and managed care organizations, in that such policy is mandatory for all entities covered by the Health Insurance Portability and Accountability (HIPAA) law, but is being ignored by private insurers and managed care organizations.
MSSNY will urge the Centers for Medicare and Medicaid Services (CMS) to require all private and managed care insurers to formally adopt the longstanding policy of CMS (reflected in ICD-10), that if a physician (1) does not know the diagnosis at the start of an encounter; (2) has not established a definitive diagnosis by the end of the encounter; and (3) is facing a “probable,” “suspected,” “questionable,” “rule-out,” or “working diagnosis” scenario, then it is acceptable for him or her to report codes for signs, symptoms, abnormal test results, exposure to communicable disease, or other reason for the visit.
MSSNY will urge CMS to require private and managed care insurers to adopt the policy of CMS (reflected in ICD-10) that when the physician does not have enough clinical information about a particular health condition to assign a more specific code (e.g. if he or she suspects a diagnosis of pneumonia but by the end of the encounter has not determined the underlying cause of the pneumonia — bacterial, et al), it is acceptable to report the appropriate “unspecified” code. (HOD 2016-252)
