According to the ICD-10-CM Guidelines, “Codes titled 'unspecified' are for use when the information in the medical record is insufficient to assign a more specific code.” Many of us experience a lack of documentation on a regular basis, and therefore know these unspecified codes all too well.
In fact, I once had a provider tell me, “It doesn’t matter where the lump in the breast was. They have breast cancer and that’s all we need to know.” And I’m sure many of you can guess what my reply was: “What if in the future, it DOES matter? What if we find out that a certain gene, medication, or population was responsible for cancer in the right upper quadrant of the left breast only?”
When ICD-10 was released in 2015, one of the rumors circulating was that payers would deny claims with unspecified diagnosis. Meanwhile, CMS stated they would be lenient with providers for the first 12 months of ICD-10-CM use. And they were lenient, as were the payers. Until now. At Healthicity, we’re seeing a lot of payers who are beginning to crack down on the use of the unspecified code when they believe greater specificity exists.
To better understand unspecified codes, I wrote a new eBrief, Solving the Mystery of the Unspecified Code, which covers a number of both real-word and hypothetical scenarios to illustrate how your organization can conduct routine audits, improve provider education, and review past denials to reduce the amount of your future denials.