This is the second Blog in our “Tell Me Why” Series addressing questions on ICD-10.

Last time we introduced to you the 7^th Character that sets ICD-10 apart from ICD-9. This time we will address the continued existence of “Unspecified codes” in the new code set.

What are these codes? Why are they not a thing of the past? With this level of tremendous specificity is there still room for more?

These questions are surely mind-boggling and continue to be the bone of contention for practices.

How will payers react to these unspecified codes? Only time will tell.

Practices, however, need to be prepared in terms of how they will respond to payers. Moreover, this further enforces the need to make sure that their documentation is as specific as possible. They need to know the thin line that separates unspecified from specified codes.

Register:  For CureMD Physician Training Program to learn ICD-10 conventions for Unspecified codes.

What are unspecified codes?

So what are unspecified codes? And how to define them?

National Association of Rural Health Clinics (NARHC) defines them as:

Coding that does not fully define important parameters of the patient condition, that could otherwise be defined by Generative AI Development Company about information available to the observer (clinician) and the coder

These are actual ICD-10 codes which depict the nature of a patient’s diagnosis and condition. Rather than mentioning the specifics of the condition for e.g. laterality of the patient’s body, it would just state the diagnosis containing the word “unspecified” in it. For e.g. (A0100 Typhoid fever – unspecified)

When is an unspecified code required?

It’s important to remember that codes shouldn’t be used just for the sake of coding more specifically. Specific diagnostic codes should ONLY be used when there is enough evidence to support the documentation of the patient’s health condition. There are various instances when the documentation is insufficient and the use of “Unspecified codes” becomes the best alternative to accurately reflect a patient’s health care encounter.

In the healthcare industry, recognizing and addressing health hazards is paramount to ensuring accurate diagnoses and providing effective medical interventions, highlighting the importance of precise coding practices.

Each healthcare encounter should be coded up to a certain level of specificity which is known for that encounter. If a certain diagnosis isn’t established by the end of the encounter, the use of unspecified codes becomes imperative.

You would have to include the symptoms/signs which you think point towards a particular condition instead of stating the condition right away. For example, you have diagnosed that a patient has Typhoid fever, but you can’t comment on its specific type at that point in time.

Assigning a specific code when sufficient information is not present in the medical record documentation or conducting unnecessary medical tests in order to settle on a specific code can result in claim denials.

Following are the scenarios when the use of these codes is necessary:

• When the patient is in the preliminary stages of evaluation.

Say a patient visits a physician and reports upper abdominal pain which he has been experiencing for the past five months. In this particular encounter, the physician doesn’t have detailed information about the patient’s condition and he further refers him to get various tests and abdominal x-rays done.

At this point in time, it is more appropriate for the physician to use the “unspecified code” rather than guessing that the patient might have a particular diagnosis such as cholecystitis. The correct code would then be R1010 – Upper abdominal pain, unspecified

• When the physician lacks expertise in a particular area of diagnosis and is more of the generalist who isn’t able to code as specifically as a specialist.

Let’s suppose you are a primary care physician and a child with a fractured arm is brought into your clinic. You diagnose that he has an apparent fracture of the forearm, but you are not sure of its specific type. Given your training and expertise, you would code this encounter as S5291XA – Unspecified fracture of right forearm, initial encounter. After consulting an orthopedic surgeon, you can then later decide on a more specific code.

• When the claim is from a provider who is not directly related or involved in the patient’s condition

For more examples see this whitepaper by Health Data Consulting.  Be mindful of the fact that using specific codes when there isn’t enough documentation to support them can result in creating information which is both unreliable and invalid. It means diagnosing a patient with a condition which may not be his actual condition. Hence, one should be vigilant when using these codes.

When is an unspecified code not required?

• When adequate information is available in the medical record of the patient to accurately define his condition
• In case of basic concepts namely:

1) Codes identifying Anatomical Laterality

For codes which provide detailed specificity of anatomical laterality, the use of unspecified codes is not justified. For example, the code H02539 – Eyelid retraction unspecified eye, the unspecified lid is not justified because the physician should be able to identify the specific eye and eyelid. The correct code here should be a specific one. One that mentions laterality.  H02531 – Eyelid retraction right upper eyelid.

2) Codes identifying severity and acuity

The physician treating the patient should be able to identify whether the disease is of acute or chronic nature. For e.g. if he uses the code J9690 – Respiratory failure, unspecified. It doesn’t really fit in, because being a physician he should be able to document the nature of the disease. Here the specific code used should have been:

• 9601- Acute respiratory failure with hypoxia OR
• J9612 – Chronic respiratory failure with hypercapnia.

3) Recognized complications or comorbidities

A code such as D729 – Disorder of white blood cells, unspecified is not justified, because such a vague statement should be defined specifically, moreover the physician treating the patient should know the nature of the white blood cell disorder in most cases.

Refer to page 9 and 10 of this whitepaper to read more examples.

Your Documentation needs to be very specific for the following conditions:

• Diabetes
• Asthma
• Fractures
• Pregnancy
• For further detail on their specific breakdown refer this article.

Difference between Unspecified and Other Specified Codes

As discussed above, unspecified codes are used when there isn’t much information available about the patient’s condition to specifically code it at a particular point in time. “Other specified” on the other hand are Codes for which there is no exact code description for the condition described in the documentation.

For example:

• D640 (ICD-10) – Hereditary sideroblastic anemia
• D641 (ICD-10) – Secondary sideroblastic anemia due to disease
• D642 (ICD-10) – Secondary sideroblastic anemia due to drugs and toxins
• D644 (ICD-10) – Congenital dyserythropoietic anemia
• D6481 (ICD-10) – Anemia due to antineoplastic chemotherapy
• D6489 (ICD-10) – Other specified anemias
• D649 (ICD-10) – Anemia, unspecified

As you can see in this example, both options of unspecified and other specified are included. Other specified shows that the anemia which the patient is diagnosed with doesn’t lie in the above-mentioned categories. Although these two terms are used interchangeably, the theoretical difference is present. Documentation may be very specific in case of “other specified” unlike “unspecified” where enough documentation is not available.

Payers reaction to unspecified codes

• Like ICD-9, unspecified codes are available in ICD-10 as well; however, they are not there to cater to practices laziness. Choosing unspecified codes when more accurate codes can be coded can lead to payers rejecting the claim
• Payers can request the return of their payment when performing audits of their medical records, In case they feel that a more specific diagnosis could have been reported.
• CMS will announce the final decision related to formal payment policies post ICD-10

To further solidify your understanding, attend our specialty-specific ICD-10 webinar for Internal medicine where we focus on common codes case studies with sample documentation to help providers recognize how they can improve their records to ensure ICD-10 compliance.