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Be Sure Your Home Infusion DX Codes are Specific (and Billable)

Written by: Mediware Bloggers on Tuesday, January 17, 2017 Posted in: Home Infusion

By: Rebecca Ingalls, Mediware Reimbursement Services

checklistFollowing the implementation of ICD-10 coding on October 1, 2015, providers were required to bill Medicare and other payers using detailed diagnosis codes that provided specific information. However, during the first year—through Sept. 30, 2016—some flexibility was allowed as users became accustomed to the new coding system. Now that the period of adjustment has ended, non-specific diagnosis codes are no longer allowed. Claims without sufficient detail will be denied.

By now, your pharmacy should have already begun billing with the required ICD-10 specificity. However, if you experienced denials, you may need to include more specific billing codes. Below are some tips to help when researching which codes to use so that you submit clean claims the first time.

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  1. Why specificity is required: ICD-10 flexibilities were intended to prevent contractors performing medical review from denying claims solely for the specificity of the ICD-10 code as long as there was no evidence of fraud. Because these medical review flexibilities have now ended, providers must utilize full code structure to accurately reflect the clinical documentation in as much specificity as possible.Many major insurers did not choose to offer coding flexibility, so many providers are already using specific codes. Avoid unspecified ICD-10 codes when documentation backs up a more detailed code. Check the coding on each claim to make sure that it aligns with the clinical documentation.

  2. Know which codes to use: Assign three-digit codes when there are no four-digit codes within the category. Assign four-digit codes if there is no fifth-digit subclassification for a particular category. Assign the fifth-digit subclassification code for those categories where it exits.Reference the link below to decide if a code is currently billable. As you navigate through the specific diagnoses, you will eventually see a pop-up list with details about which codes are billable.


  1. Go beyond the family: According to CMS, the “family of codes” is the ICD-10 three-character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. Prior to October 1, 2016, claims merely had to be in the correct family due to audit flexibilities, but, again, that’s no longer the case. For instance, category K50 (the Crohn’s disease family) includes multiple specific codes that capture information on the nature of the disease. Examples include:
    • K50.00 – Crohn’s disease of small intestine without complications
    • K50.012 – Crohn’s disease of small intestine with intestinal obstruction

In most instances, codes will require more than three characters to be valid. Visit this link for more information:


  1. Manage the updates internally: Mediware’s clearinghouse partner, ZirMed, has many suggestions on how to manage detailed ICD-10 coding. These include:
    • Review code additions to identify if more specific codes are available for common diagnosis or procedure codes
    • Ensure that your EMR and billing systems are updated with the new additions (they may appear automatically as part of normal system updates)—also update any proprietary forms such as intake forms and superbills with the new codes
    • Review deleted codes and remove from proprietary forms such as intake forms and superbills as applicable
    • Review revised codes for new code descriptions (intent may have changed) to ensure proper code usage
    • Train staff on updates relevant to the facility or practice
    • Review and audit current unspecified or non-specific code usage
    • Continue to track claim rejections and denials for unspecified or non-specific code use.

For more information, visit ZirMed’s helpful ICD-10 helpful updates:

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