Unspecified or Specified ICD-10-CM codes

Vijayarani Sivakumar

Published On - December 07, 2021

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?”

Examples:

• M32.9—Systemic Lupus Erythematosus, unspecified
  SLE NOS
  Systemic lupus erythematosus NOS
  Systemic lupus erythematosus without organ involvement
• It is appropriate to use the unspecified code M32.9 for lupus, because there is no other code in the category for just lupus without involvement.

• M32.10—Systemic Lupus Erythematosus, organ or system involvement unspecified
• Considering the level of information available to the physician, the findings at the time are nonspecific, and the patient may need further work-up. This code would be more appropriate than a code that guesses at the fact that the patient may have a specific organ or system involvement that has not been confirmed.

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.

• M25.46—Effusion, knee
  M25.461—Effusion, right knee
  M25.462—Effusion, left knee
• The clinician should be able to code the site/side, and in this case, whether it is the left or the right.

• M25.469—Effusion, unspecified knee
• There is little justification for the use of this code, because the specific knee/anatomical site should be known to the clinician treating the patient.

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