2018 ICD-10 code update exercise: Consider the audience

August 11th, 2017 / By Barbara Aubry, RN

I am a member of a team that works directly with CMS on the yearly code update process for their National Coverage Determination policies (NCDs). Our team accesses, refines and refines again the lists of ICD-10-CM and PCS codes as they are released in spring with addenda released in summer. We carefully comb through each NCD policy looking at both diagnoses and procedures to determine if there are new codes that—based on current policy language – should be considered for inclusion in a given policy. We also use keyword and other search scenarios when reviewing the thousands of new codes.

Once our lists of possible code inclusions are created they are submitted to CMS where their medical officers further review the suggestions. Those data lists are then reviewed by the adjudication contractors and more feedback is provided to CMS. This is a time-consuming process with many sets of eyes reviewing, tweaking and reviewing again in order to create the final lists. Once the determinations are completed, the NCD code spreadsheets are updated with the new inclusions. This process is repeated again once the CPT and HCPCS codes for 2018 are released. Rest assured that many hours of review and determination are invested in the updates. CMS’ goal is to provide a robust list of the most specific codes possible. CMS is weeding out the “unspecifieds” as more specific code options are released.

I want to share an example of this process, highlighting additions to NCD 220.13, Percutaneous Image Guided Breast Biopsy. In 2017 there were 66 ICD-10 diagnosis codes in the policy. For 2018, 14 new diagnoses codes were released that meet inclusion parameters for this NCD:


Unspecified lump in unspecified breast


Unspecified lump in right breast, unspecified quadrant


Unspecified lump in right breast, upper outer quadrant


Unspecified lump in right breast, upper inner quadrant


Unspecified lump in right breast, lower outer quadrant


Unspecified lump in right breast, lower inner quadrant


Unspecified lump in the left breast, unspecified quadrant


Unspecified lump in the left breast, upper outer quadrant


Unspecified lump in the left breast, upper inner quadrant


Unspecified lump in left breast, lower inner quadrant


Unspecified lump in axillary tail of the right breast


Unspecified lump in axillary tail of the left breast


Unspecified lump in the right breast, subareolar


Unspecified lump in the left breast, subareolar

Though CMS wants providers to use the most specific code possible, N63 (Unspecified lump in breast) is included in the current diagnosis list. This year, that code is further extrapolated to N63.0 (Unspecified lump in unspecified breast). In an effort to follow the specificity goal, I suggested removing N63 and N63.0 from the policy since the new codes above provide greater specificity with regard to breast lumps. I expect to hear push back and I am not certain CMS will agree.

At times it appears (to me) the industry requests inclusion of unspecific codes when there are better options available. Perhaps that is for provider convenience? I’m not sure, but is it fair to a patient to assign N63 or N63.0? If a provider performs a biopsy, surely they know the laterality? If they don’t accurately document this information, should HIM professionals query the provider? This information (or lack of) becomes an official record that follows the patient.

I understand the need for certain unspecified codes for those instances when a new patient provides a history and recalls a pathologic vertebral fracture but does not know the specific level (for example). But with appendages as specific as arms, legs, ears, eyes, hands, feet and breasts I feel certain we can do better. And I believe most patients can recall the laterality of their breast biopsy. For those who cannot, they likely are not able historians—their recollections would require verification for accuracy.

An August 2017 article in JAMA Network titled “Characterizing the Source of Text in Electronic Health Record Progress Notes” revealed less than one-fifth of progress note content was manually entered. JAMA used a new EHR tool that “distinguishes manual, imported and copied text in hospital progress notes with character-by-character granularity.” For the first time they were able to clearly calculate the instance of what some call plagiarism.

Healthcare providers and HIM professionals need to be aware of the new member of the EHR audience. With the current push toward more patient participation and responsibility for personal health, electronic access to medical records is becoming more common. In my opinion, any patient would be concerned if they found their diagnosis to be either N63 or N63.0 when accessing their medical record or claims data. Poor documentation by the provider and concomitant use of unspecified codes when many better options are available may give the impression that their healthcare providers either didn’t know which breast they operated on or didn’t take the time to document properly. It also makes it appear that the HIM professional agreed with the provider. With the high rate of cut-and-paste in EHRs, this less-than-specific data will be dragged forward in the patient record ad infinitum, which is not fair to patients. Please tell me if you disagree. I welcome your comments below.

Barbara Aubry is a regulatory analyst for 3M Health Information Systems.