At UASI we have coded thousands of health records, and we are seeing where clinical documentation will need to improve to be able to use the ICD-10-CM/PCS code sets efficiently. One of the trends we are seeing is that unspecified code rates are indeed higher with ICD-10-CM than with ICD-9-CM. But you learn very interesting things when you look at what is assigned to unspecified codes in ICD-9-CM, in ICD-10-CM, or in both systems.

For instance, there is a significant overlap. The majority of the conditions assigned to unspecified codes, are unspecified in both classification systems. This is an indication that a lot of the things we have difficulty with today, while coding with ICD-9-CM, will continue to remain a focus after we transition to ICD-10-CM/PCS.

Another interesting point about the unspecified code rates is that they do seem to directly correlate with the presence or absence of an effective clinical documentation improvement program. In general, we’ve observed that hospitals with an effective CDI program, have lower unspecified code rates overall and the unspecified code rates in ICD-9-CM and ICD-10-CM are closer to the same. In other words there is maybe only a 5% increase with ICD-10-CM compared to ICD-9-CM, representing a narrower gap to bridge.  These observations certainly reaffirm the importance of clinical documentation improvement efforts in the ICD10 transition plan.

Mary H. Stanfill - Vice President of Health Information Management Services    

May 14, 2012