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“Didn’t ICD-10 get rid of unspecified codes? Isn’t ICD-10 more specific than ICD-9”

These are two questions I’ve heard over and over during the period leading up to ICD-10 implementation. And as we near the big day of Oct. 1, 2014, these questions still are popping up in one form or another. These are not simple “yes or no” questions. As with everything in the ICD-10 universe, the answers depend on intent. And it should be understood that the process of coding is not a simple process. Coders are continuously asking themselves, their peers, and their physicians questions in order to reach the most appropriate conclusions. They’re after those conclusions that ensure that not only do their claims sail through the adjudication process, but also that the claims are paid as expected and supported by the documentation. This is the goal.

In ICD-9 there are a plethora of codes that are considered non-specific. These are typically identified with wording such as “not otherwise specified” or “not elsewhere classified,” which do not mean the same thing, in theory. If, however, you are a user of diagnosis data, there is little difference between these two concepts. Both lead to the exact same lack of information. If you are the coder assigning the code, the “not otherwise specified” means that there was no documented evidence to allow for the assignment of a more specific code. This could be a result of the diagnosis process, for which the physician doesn’t have enough evidence to assign a more specific code. And sometimes, there is simply not enough documentation to assign a specific code. If there isn’t a code for the documented condition, then “not elsewhere classified” is the appropriate choice. These nuances are not lost in ICD-10.

In ICD-10, we have a more straightforward pair of descriptions of the non-specific diagnosis: “unspecified” and “other/other specified.” Surely ICD-10 uses these terms sparingly, since it is a more specific code set? Well, no – no it doesn’t. But here are a few scenarios that illustrate why non-specific codes are necessary and completely acceptable:

  • Evidence supporting a more specific diagnosis is required, with lab tests or imaging deemed necessary. Since the results from these may come days after an initial visit, an unspecified code is necessary to code the first visit until a more specific diagnosis can be confirmed.

  • A patient’s true condition cannot be coded to a specific diagnosis because there is no current classification. In this case “other” or “other specified” would be the most appropriate.

  • A patient’s medical history is incomplete or the patient is unable to answer questions, such as in an emergency situation. This means that the diagnosis depends solely on the physician’s observations, which may not include information that is required to assign a more specific code.

And while these scenarios happen all the time in the real world of patient care, there’s also misuse of unspecified codes. Unspecified codes tend to be a default for some who assign codes. They are like the 1970s-era wallpaper in your kitchen that has been plastered over with pictures and trinkets. Maybe you’ve even covered it entirely, but that retro wallpaper is still there. Unspecified codes stick in our memories and can come to mind when we see a certain diagnosis. If I say “type 2 diabetes” you may automatically recall 250.00, which is “Diabetes mellitus without mention of complication, type II not stated as uncontrolled.” It is no coincidence that this is the most frequently used diabetes code. Or maybe congestive heart failure is equal to 428.0, again an unspecified code. This doesn’t mean that every time these codes are reported, they aren’t the best choice, but it begs the question: Are we asking the right questions? Are we missing something crucial in our documentation that identifies a manifestation or complication associated with diabetes? Was there evidence indicating what type of congestive heart failure a patient has? These details are critical information that can make a big difference for downstream users of the diagnosis codes.

And now, with ICD-10 and its increased specificity, there are more specific “unspecified” codes. I know it sounds oxymoronic, but it’s true. One of the best examples is found in the designation of laterality. The condition or injury is the first part of the classification, followed by what side of the body the condition or injury is affecting. But there is also the option to indicate that the side of the body is “unspecified.” In this coder’s humble opinion, there doesn’t seem to be a valid reason to ever indicate that laterality is “unspecified.” This is required documentation. Even if a patient is unable to respond, an evaluation should reveal what arm, breast, leg, or eye is affected, and therefore, reporting the unspecified code for laterality is not appropriate and should be avoided.

Keep in mind that as we begin to use ICD-10 codes, payors will be paying close attention to the codes that are coming through their claims systems. It is very possible that they will begin to implement parameters around what “unspecified” codes are acceptable and which are not. It is in everyone’s best interest to ensure that we are:

  • Asking the necessary questions;

  • Documenting the details; and

  • Coding accurately and in support of the documentation.

I am an optimist. I believe that once the dust settles and the anxiety and stress of implementation are merely a memory, we will begin to see the inherent value in ICD-10. And we will begin to leverage all of its bells and whistles while reserving the use of “unspecified” for those situations that truly warrant it.

About the Author

Mandy Willis is a Certified Coding Specialist and AHIMA Approved ICD-10 Trainer with 15 years of experience in the healthcare industry. She has worked in the small physician practice environment, commercial payer and Medicare and Medicaid. Currently, her focus is on assisting all sectors of the healthcare industry in making the transition to ICD-10.

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