One of the main selling points of the ICD-10 code set is the incredible degree of specificity it provides. As such, the protocol for selecting the correct ICD-10 code is to choose the one that represents the patient’s condition in the most detailed way possible. And that means that, in general, submitting “unspecified” diagnosis codes—something you might have grown accustomed to with ICD-9—is a big no-no. In fact, doing so could lead to claim denials. But as the saying goes, there’s an exception to every rule—and in this case, that exception stems from differing definitions of the word “unspecified.” As Joseph C. Nichols of Health Data Consulting (HDC) states in this report, “While it is true that we should be as specific as possible to assure the best quality information, most of the discussions around unspecified codes don’t really get at what ‘unspecified’ means relevant to codes let alone when they should or shouldn’t be used.”
The True Meaning of Unspecified
This presentation by the National Association of Rural Health Clinics (NARHC) defines unspecified coding as “Coding that does not fully define important parameters of the patient condition that could otherwise be defined given information available to the observer (clinician) and the coder.”
In this context, the concept of “unspecified coding” seems totally independent of the use of “unspecified codes.” It merely refers to coding that does not account for details that are, in fact, available to the coder.
“Unspecified codes,” on the other hand, are actual ICD-10 codes that represent actual patient conditions and diagnoses—albeit not to the standard of specificity ICD-10 is meant to deliver. For example, unspecified codes do not indicate the anatomical laterality—such as right, left, or bilateral—of injuries and other conditions. Most unspecified codes simply state the diagnosis and contain the word “unspecified” within their descriptions (e.g., S13.101, Dislocation of unspecified cervical vertebrae). But when does the use of these codes fall under the umbrella of “unspecified coding” as discussed above? And how do you know when it’s acceptable to use an unspecified code?
When Can You Use Unspecified Codes?
The NARHC and HDC have identified the following examples of situations in which it may be acceptable to use an unspecified code:
- The clinician does not yet know enough about the patient’s condition to select a more specific code (because the patient is still in the early stages of evaluation, for example)
- The provider is not directly related to, or involved with, the diagnosis the code represents
- The clinician does not have enough expertise in the area of the diagnosis to describe the condition to the degree of specificity a specialist would be able to provide
To see specific examples of the scenarios above, refer to page eight of this document. If you’re curious as to why the coders or clinicians in these instances wouldn’t simply choose a more specific code—even if they didn’t necessarily know all the facts about the case—here’s a word of caution from HDC’s Nichols: “Forcing coders to use a ‘specified’ code may result in the unintended consequence of creating misinformation that assumes something is true when there is no real evidence to support that level of specificity.” And recording inaccurate diagnoses for patients could compromise not only the quality of their treatment, but also the historical accuracy of their medical records. For that reason, it’s better to use an unspecified code of which you are confident than a specific code of which you are unsure.
When Should You Steer Clear of Unspecified Codes?
Per the NARHC and HDC, coders and practitioners should not use unspecified codes when:
- They have enough information to define the condition in a more detailed way
- They lack knowledge regarding basic concepts such as:
- Laterality (e.g., right, left, bilateral, or unilateral)
- Anatomical location
- Trimester (of pregnancy)
- Type of diabetes
- Established complications or comorbidities
- Information about severity, acuity, or other parameters
- They are providing care that necessitates a more specific diagnosis
- They are specialists, and thus should be able to provide more detailed information about a particular condition
Check out page nine of this document to see specific examples of the scenarios above.
Remember: coding, like documentation, is all about justification. Just as you should be able to justify the way you document, you should be able to justify the way you code. So, if you use an unspecified code simply because you don’t want to take the time to locate a more specific one—even though you have the tools necessary to do so—you’re definitely putting yourself at risk for some pretty terrible consequences (I’m talking claim denials). If you don’t feel like the codes you’ve provided give a complete picture of a patient’s condition, chances are that your payers will feel the same way. Essentially, listen to your gut and use common sense—that way, you’ll always be able to justify your coding decisions.