How to Use Undefined ICD-10 Codes?
ICD-10 codes is a more accurate coding system than ICD-9 since it has five times as many codes. It follows that healthcare professionals often have questions about how to use nonspecific codes or choose not to use them at all.
Unspecified codes were frequently used in the ICD-9 coding system. On the other hand, utilizing codes in the ICD-10 coding system without the necessary standards may lead to claim rejections and denials.
Because of this, a lot of doctors get wary about using nonspecific codes. They just don’t trust them much. This article, though, breaks it down and gives examples, shows when they fit, and drops a few tips on how to keep their use low.
Therefore, you should follow this tutorial through to the finish to clear up any confusion.
Unspecified Codes: What Are They?
Unspecified codes are incomplete codes that leave out important information about the patient’s condition that could have been ascertained using the coder’s and doctor’s information.
Unspecified simply means too vague, although more specific information is available.
In this case, the word “unspecified” kind of sounds negative. But here’s the twist: in ICD-10, those are the codes that describe diagnoses, just not in full detail. They’re called nonspecific codes. And instead of saying which side or exact detail, the code just ends with “unspecified.”
And that’s where the confusion really starts. When does it even make sense to use an “unspecified” code, right? What does it mean in practice? Sometimes it’s fine, sometimes not. So, when exactly is it okay to go with that kind of code?
When Is It Necessary To Use An Unspecified Code?
Do not forget! It is not appropriate to use codes merely to submit a claim and receive payment. Only when the patient’s medical condition is sufficiently documented should certain diagnostic codes be used. When documentation is insufficient, nonspecific codes are frequently the most accurate approach to accurately represent a patient’s medical encounter.
In the healthcare industry, precise coding procedures are vital since it is necessary to recognize and control health risks in order to provide precise diagnoses and administer the right medical treatments.
Every medical encounter must be coded by healthcare professionals with a level of specificity particular to that visit. Nonspecific codes are required if a specific diagnosis cannot be made before the end of the interaction.
Therefore, you should describe the signs or indicators of a certain sickness rather than revealing the ailment right away. For instance, it is impossible to specify the specific form of typhoid fever even if you have diagnosed a patient with it.
Claim denials can occur when a code is assigned based on insufficient information in the medical record or when unnecessary testing is ordered to identify a code.
Initial Phases of Evaluation
Imagine a patient has been dealing with upper belly pain for five months. Finally goes to the doctor. The doctor doesn’t have the full picture yet, so they suggest a bunch of tests. Yeah, that includes an abdominal X-ray.
Instead of guessing the cause, such as cholecystitis or another particular ailment, the clinician would be better off using the “unspecified code” at this time. The proper designation would therefore be R1010-Unspecified upper abdominal pain.
Absence of Knowledge in a Certain Field
Picture a young patient walking in, limb broken. You’re the primary care doctor. Looks like a forearm fracture, but the type? Not clear yet. So, you code it as S52.91XA, right forearm fracture, unspecified, initial encounter. Later, after checking with an orthopedic surgeon, you can switch to a more specific code.
When Is It Not Necessary To Use An Unspecified Code?
Some of the situations when using an ICD-10 non-specified code are never appropriate and are covered below:
Symbols for Anatomical Laterality
It is unacceptable to utilize non-specific codes for diagnoses that provide precise specificity of anatomical laterality. For example, the provider should be able to identify the specific eye and eyelid; therefore, the unidentified lid in code H02539-Eylid retraction unknown eye is not justified. You have to use a certain code here. H02531: Retraction of the right eye’s upper lid.
Codes for Determining Acuity and Severity
The treating physician should be able to identify whether the sickness is acute or chronic. For instance, the code J9690—Respiratory failure, unspecified—can be used. It doesn’t fit in because you should be able to document the illness’s specifics as a provider. In this case, J9612—chronic respiratory failure with hypercapnia—or J9601—acute respiratory failure with hypoxia—should have been the exact code.
Known Comorbidities or Complications
Since the patient’s treating physician should be aware of the nature of the white blood cell illness, a code such as D729, illness of white blood cells, unspecified, is not justified.
Additionally, the following requirements should be met by your documentation:
- Pregnancy
- Fractures
- Asthma
- Diabetes, and more.
Other vs Unspecified Specified Codes
Within a category of codes, you might come across “unspecified” and “other specified” codes. These two codes have different meanings. “Other” codes show that while there are some diagnosis codes, none of them apply to the patient’s condition. In this case, the medical professional knows the cause of the sickness, but there isn’t a code for it.
On the other hand, the undefined code means that the diagnostic was made without knowing the status. In the future, an “unspecified” diagnosis could be recorded more accurately if additional information about the patient’s condition becomes available.
Example
There are multiple codes for hypothyroidism. If there is a recognized cause for the patient’s hypothyroidism that isn’t addressed by one of the existing codes, code E03.8 would be used. If the patient’s type of hypothyroidism is unknown, code E03.9 would be applied.
4 Ways to Reduce the Use of Unspecified Codes
Unspecified codes frequently result in rejections and denials of claims. As a result, medical procedures ought to make an effort to identify the diagnosis and refrain from utilizing vague codes needlessly.
Determine
Since “not otherwise specified” or “NOS” is typically included in their Tabular List explanation, unspecified codes are simple to identify.
Frequency
Now that you can recognize these codes, the next step is to determine how frequently you report them. To do this, you can use an electronic health record (EHR) system.
Running a report by code is an option available in most software. To find out which nonspecific codes you have billed the most, look into the activities over the previous three months. Additionally, you can use this information to find out who in your workplace is assigning these codes.
Teach Staff Members
The information you collected in step 2 can be used to train your employees. Here, the goal is to teach students how to look for better opportunities. The statement might be as simple as saying that ICD-10 offers more options than ICD-9 and that some codes that were ambiguous in ICD-9 are now more precise in ICD-10.
Providing Training
Work together with your medical professionals to improve the patient’s records’ specificity. The number of times your programmers need to choose an undefined code in the first place will be significantly decreased. By following this approach, the issue can be avoided later on in the chart-coding procedure.
When your providers are learning, you should equip them with materials to help them absorb the necessary information. To acquire the information you need, try making a simple question form that allows your providers to tick a box or do another similar action. It might say on your form:
More specifics are needed to code this patient as precisely as possible. Please tick the corresponding boxes below:
Mark, if you have type 1 or type 2 diabetes.
Kindly indicate the state of treatment: Sequential, Initial, and Sequel.
Conclusion
Unspecified codes and their correct usage were covered in detail in this tutorialAdditionallyll,y improve your comprehension, we explained how unspecified codes vary from other specified codes. We also provided some advice on how to reduce the usage of unidentified codes.
However, in many situations, using an unidentified code is the only option. However, these occurrences must be rare. Make sure you have flawless documentation to back up your coding choice and defend your position when you are faced with it.
