Most Unspecified Diagnoses will be invalid come PDGM 2020

By Nancy Joyce, RN, BSN, HCS-D, HCS-O

As we all know, PDGM is coming, and with it comes many changes, not only for home health clinicians, but for physicians as well.

CMS will now require much more specific diagnosis codes than previously used.  One of the areas CMS has targeted is the use of “unspecified” codes (any code with the word “unspecified” in it), and also the “R” codes.

​“Unspecified”

In the world of coding, any diagnosis with the term “unspecified” means:
A more specific diagnosis may be available for a particular diagnosis

The physician has not provided any further diagnostic detail regarding a particular diagnosis-in other words, the physician has not given enough information to use a more specific code.

For example:
 
The physician sends a referral with the diagnosis “Congestive Heart Failure”. With only this information, the correct code would be “Heart Failure, Unspecified”. 
 
The code that would be assigned for this diagnosis will result in a denial of the claim by CMS.
Why?  Because heart failure can be further broken down into subcategories for more detail.
This means that it will be necessary to find out if the heart failure is systolic, diastolic, or both. It also means getting verification of whether the heart failure is acute, chronic, or acute on chronic.
 
Under the new payment system, unspecified diagnoses will need more clarification from the physician, which means that clinicians will have to become comfortable with contacting the physician (or his representative) to get more details.  

Here are a few other examples that CMS has identified:

• Atrial Fibrillation
• Wounds (which will be addressed in more detail in a later bulletin)
• Renal Failure
• Fractures

This is just a very small list, but these are items seen commonly in the home health setting.
 
To make is just a little more difficult, some unspecified codes will be allowed, but only because there is no further classification to the diagnosis. 

For example, COPD. If the COPD is not exacerbated, or accompanied by a lower respiratory tract infection, there is no other code that can be used except “COPD, unspecified”.  Very confusing!
 
​“R” Codes
 
​Then there are the “R” codes.  These codes are commonly referred to as “symptom” codes, which are generally only used when definitive diagnosis is not yet made.  In other words, if the tests are not back yet, or there will be no further investigation needed. 
Some of the common R codes used are:
* Nausea/Vomiting
* Diarrhea
* Difficulty walking (PT codes will also be discussed in a later bulletin)
* Vertigo
* Syncope
 
So, you probably have more questions than answers at this point.  Everyone does, and it seems CMS is making changes almost on a daily basis.

CODE4Five coding team will:

• Notify you if there is an invalid diagnosis
• Provide details to help you obtain the needed information from the physician
• Be available to answer your questions when you identify a diagnosis that you think might be invalid

​You will need to follow your agency’s policy for obtaining and documenting any needed information in a timely manner, so that coding can be completed according to CMS guidelines.
 

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Author

Nancy is one of our dedicated QAs who values the importance of research and fact-based assessments and quality review.  She likes writing on her free time, when she's not too busy smelling the flowers.