Laboratory Question for the Week of October 3, 2016

Laboratory Compliance Question of the Week


Is there a new Medicare policy related to not reporting unspecified codes? This would be a real problem for our independent lab, which has a hard time getting specific information from some of our ordering physicians.


In July 2015, the Centers for Medicare & Medicaid Services (CMS) announced that, during the first year of ICD-10-CM, Medicare administrative contractors (MACs)—but not necessarily other major insurers—would not deny claims based solely on the specificity of the diagnosis code.

The new fiscal year for diagnosis codes began October 1, 2016, which means an end to this flexibility, and all CMS review contractors can use coding specificity as the reason for an audit for a denial of a reviewed claim to the same extent that they did prior to October 1, 2015. They will notify providers of coding issues they identify during review and of steps needed to correct those issues to the same extent that they did prior to October 1, 2015.

As a result of the above, some facilities and practices are now struggling to put processes in place to make sure that specific clinical indications are obtained. Ordering physicians should always provide detailed and accurate information so that codes can be assigned to the highest level of specificity.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.