GA Medicaid policy on unspecified codes and the requirements for ICD-10

GA Medicaid policy on unspecified codes and the requirements for ICD-10

Medicare says "Unspecified ICD-10 Codes" are good enough to be paid, but Georgia Medicaid says no. For more information, review the Georgia Department of Community Health ICD-10 FAQ.

Q: Could you explain the Medicaid policy on unspecified codes and the requirements for ICD-10 effective October 1, 2015?

A: NOS, or “not otherwise specified” codes will be denied as there is not enough clinical documentation to determine the diagnosis. NEC codes, or “not elsewhere classified” will be supported as this means there is not an appropriate or an existing ICD-10 code to support it.

Clinical justification is required if providers use an NEC code. The physician is required to bill at the lowest specificity or diagnosis code level selecting the most appropriate specified code. The physician’s documentation must be clear, complete and concise to support the code billed.

Example: A patient is seen for injury to the right and/or left eye, but the provider bills using a diagnosis code of “other” as an unspecified code. Unless the provider has documentation that there is a third eye, then this claim with an unspecified diagnosis code of “other” would be denied."

Read more on the ICD-10 FAQ from the GA Department of Community Health

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