According to ICD-10-CM Official Guidelines
for Coding and Reporting , “unspecified codes are to be used when the
information in the medical record is insufficient to assign a more specific
code.” In my opinion, this can be the case with testing, when lab work or
cultures do not support the more specific code. In the case of laterality,
however, it’s an issue of provider documentation. Examples of laterality issues
can be seen in fracture, cyst, bursitis and neoplasm coding.
Coding specificity is critical to assure that data about health care
represents an accurate reflection of patient conditions and the procedures,
goods or services required to improve or maintain those conditions. It is
important to understand what “unspecified”
means however in order to improve data quality and avoid the use of more
specific codes for payment purpose rather than to reflect the patient condition
as accurately as can be determined at any point in time.
There is no justification
for “coding for payment”. Documentation and coding should only represent the realities of the patient
condition based on the assessment by the clinician, and only at the level supported by
the assessment and the documentation of
the details of that assessment.
At present, neither CMS nor third-party
payers are providing a list of unspecified codes that are unacceptable and
likely to be denied, so coding professionals should review denials and watch
for patterns to see which codes are triggering denials.
Depending
on the situation, legitimate uses do exist for a less specific or unspecified
code. The ultimate question comes down to: “Does the code reflect as accurately
and precisely as possible the patient’s condition or the services performed to
maintain or improve that condition for that encounter?”
The
use of any other code within this category would be based on the fact that the
patient has some organ involvement that is confirmed and documented. Codes
M32.11–M32.15 are specific to organ involvement. Additionally, M32.19 (other
organ or system involvement in systemic lupus erythematosus) should be
used if the patient has involvement in an organ or system not listed in the
category, and M32.8 (other forms of systemic lupus erythematosus) refers to the
provider not knowing the nature or specifics of the condition.
However,
for codes that provide or require specificity for laterality (left, right or
unspecified side), every provider should be able to document right vs. left, as
well as the anatomical site.
We
do not know how payers will handle these unspecified codes, but practices need
to be prepared to respond as they receive feedback from the payers. An
additional complication is that all payers will not handle these codes the same
way at the same time. Therefore, it’s important to be acutely aware of the
nuances around the appropriate use of unspecified codes
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