ICD-10 has five times more codes than ICD-9, making it a more precise coding system. Thus, it makes sense that healthcare practitioners frequently wonder how to use unspecified codes or avoid using them altogether.
In the ICD-9 coding system, it was common to use unspecified codes. Contrarily, in the ICD-10 coding system, using codes without proper specifications could result in claim denials and rejections.
As a result, many healthcare providers fear using nonspecific codes. This guide will help you understand them by discussing scenarios explaining their use cases, and sharing tips to limit their use.
So, to clear your CONFUSION, you should read this guide till the end.
What Are Unspecified Codes?
Unspecified codes refer to incomplete coding that omits crucial details about the patient’s condition that could have been determined with the information available to the physician and the coder.
Simply put, unspecified means overly general, while more precise information is accessible.
Yes, “unspecified” does carry a negative connotation in this context. On the other hand, unspecified codes are ICD-10 codes that define diagnoses. However, the explanation of the code concludes with “unspecified” rather than containing specifics like laterality.
This is where the confusion resides. When does using an unspecified code make sense about what “unspecified” means? And under what circumstances is using this type of code genuinely acceptable?
When Is An Unspecified Code Required?
Remember! Codes shouldn’t be employed only for the sake of creating a claim and getting reimbursement. The use of specific diagnostic codes should only occur when the patient’s medical condition is adequately documented. In many situations, using unspecified codes is the most accurate way to appropriately depict a patient’s medical interaction when the documentation is inadequate.
Precise coding practices are crucial in the healthcare business since it is essential to identify and manage health dangers to provide accurate diagnoses and provide appropriate medical interventions.
Healthcare providers must code each medical encounter with a degree of specificity unique to that visit. If a specific diagnosis is not established by the end of the encounter, nonspecific codes become necessary.
Therefore, rather than announcing the ailment immediately, you should explain the symptoms or signals indicating a specific condition. For example, you may diagnose a patient with typhoid fever, but remarking on the exact type is impossible.
Claim denials may arise from assigning a specific code based on inadequate information in the medical record or by ordering needless medical testing to determine a code.
Preliminary Stages of Evaluation
Let’s say a patient goes to a physician and complains of having upper abdominal pain for the previous five months. In this instance, the healthcare provider advises the patient to have multiple tests, and an abdominal X-ray is performed because of the lack of comprehensive knowledge of the patient’s condition.
Right now, it makes more sense for the provider to use the “unspecified code” instead of speculating the reason, e.g., cholecystitis or another specific illness. So, R1010 – Upper abdominal pain, unspecified would be the appropriate code.
Lack of Expertise In An Area
Assume you work as a primary care physician, and a young patient comes into your office with a fractured arm. Although you are unsure about the exact nature of the fracture, you diagnose him with an apparent forearm fracture. Now, you will code this encounter as S5291XA – right forearm fracture, unspecified, initial encounter, based on your training and experience. After speaking with an orthopedic surgeon, you can choose a more precise code.
There is also a third scenario in which you can use unspecified code. It is when the claim is from a provider who wasn’t directly involved in the patient’s treatment.
When Is An Unspecified Code Not Required?
Discussed below are some of the scenarios where you should never use a non-specified code in ICD-10:
Codes Identifying Anatomical Laterality
The use of non-specific codes is not acceptable for diagnoses that offer detailed specificity of anatomical laterality. For instance, the unspecified lid in code H02539 – Eyelid retraction undetermined eye is not justified because the provider should be able to identify the particular eye and eyelid. Here, you must use a specific code. H02531 – Retraction of the top lid on the right eye.
Codes Identifying Severity and Acuity
It should be possible for the treating physician to determine if the illness is acute or persistent. For example, if you use the code J9690 – Respiratory failure, unspecified. It doesn’t fit in because, as a provider, you ought to be able to record the specifics of the illness. Here, the precise code should have been J9612 – Chronic respiratory failure with hypercapnia or J9601 – Acute respiratory failure with hypoxia.
Recognized Complications or Comorbidities
A code like D729, illness of white blood cells, unspecified, is not warranted because the patient’s treating physician should know the specifics of the white blood cell illness.
Besides, your documentation should be detailed under the following conditions:
- Asthma
- Diabetes
- Pregnancy
- Fractures, etc.
Unspecified vs Other Specified Codes
You may find “unspecified” and “other specified” codes within a category of codes. The meanings of these two codes are different. “Other” codes indicate some diagnosis codes exist, but the patient’s condition is not covered by any of them. In this instance, the healthcare provider is aware of the reason behind the illness, but there isn’t a code for one.
Contrarily, the unspecified code indicates that the state was unknown during the diagnosis. If new details about the patient’s illness become available, an “unspecified” diagnosis might be coded more precisely in the future.
Example
There are several hypothyroidism codes. Code E03.8 would be used if the patient’s hypothyroidism has a known cause that isn’t covered by one of the current codes. Code E03.9 would be used if the patient’s type of hypothyroidism is unknown.
| Codes | Description |
|---|---|
| E03 | Other hypothyroidism |
| E03.0 | Congenital hypothyroidism with diffuse goiter |
| E03.1 | Congenital hypothyroidism without goiter |
| E03.2 | Hypothyroidism due to medicaments and other exogenous substances |
| E03.3 | Postinfectious hypothyroidism |
| E03.4 | Atrophy of the thyroid (Acquired) |
| E03.5 | Myxedema coma |
| E03.8 | Other specified hypothyroidism |
| E03.9 | Hypothyroidism, unspecified |
4 Steps to Limit Your Unspecified Codes Use
The use of unspecified codes can often lead to claim denials and rejections. Therefore, healthcare practices should strive to specify the diagnosis and try to avoid using unspecified codes unnecessarily.
Identify
Unspecified codes are easily identified since their Tabular List explanation usually includes the phrase “not otherwise specified” or “NOS.”
Frequency
The next step is to decide how often you report these codes now that you can identify them. You can use an electronic health record (EHR) system to accomplish this.
The majority of software offers the option to run a report by code. Review the activity of the last three months to determine which unspecified codes you have billed most frequently. Besides, you can determine from this data who in your office is allocating these codes.
Educate Staff
You can use the data you gathered in step 2 to educate your staff. The aim here is to train them on how to search for better possibilities or ask clinicians for further details to select a more precise diagnosis code. It might be as easy as stating that ICD-10 provides more alternatives than ICD-9 and that certain codes that were unclear in ICD-9 are now more specific in ICD-10.
Train Providers
Collaborate with your healthcare providers to increase the specificity of the patient’s record. Your coders will be able to drastically reduce the number of instances where they have to select an undefined code in the first place. By adopting this strategy, the problem is identified early on and prevented from developing later on during the chart-coding process.
You should give your providers resources during their education to facilitate their assimilation of the required knowledge. Try creating a straightforward question form, enabling your providers to check a box or perform another comparable action to get the information you are missing. Your form may state:
To accurately code this patient with the utmost level of specificity, more details are required. Kindly check the appropriate boxes below:
- Please mark: Diabetes Type 1 or Type 2
- Please mark treatment status: Initial, Sequential, Sequela
For the unversed, the difference between initial, sequential, and sequela encounters is described below:
| Initial | Sequential | Sequela |
|---|---|---|
| An initial encounter (Character “A”) describes a care episode in which the patient is actively being treated for their ailment. | An episode of care during which the patient receives routine treatment for the disease during the healing or recovery phase is known as a sequential encounter (character “D”). | When complications or conditions develop as a direct result of an injury or condition, a sequela (Character “S”) is applied. In ICD-9, these were known as “late effects”. |
Bottom Line
This guide comprehensively discussed unspecified codes and how to use them properly. Besides, we shared how unspecified codes differ from other specified codes to strengthen your understanding. Additionally, we shared some tips to help you limit the use of unspecified codes.
However, there is no other choice except to use an unspecified code in some cases. But, these instances need to be infrequent. When confronted with them, ensure your documentation is impeccable to support your code selection and defend your claim.
