How to Find the Specific Code You’re Looking For.
If you were reviewing a medical record and it stated, “A patient presents with a broken arm,” you might find yourself up in arms, asking yourself, “Which arm, and which bone is broken? Is it displaced? Is it open?” And you wouldn’t be alone.
As coders, auditors, and billers, we’re trained to spot the lack of specificity in documentation. But when the answers are not evident in the documentation, you’ll have to use an unspecified code. We use these “unspecified” codes when the medical record’s information is insufficient to assign a more specific code. But now that some payers are cracking down on the use of the unspecified code, how do we start applying more specificity?
Download our latest eBrief, Solving the Mystery of the Unspecified Code, written by resident expert, Lori Cox, where she will teach best practices, including:
- Looking at Past Denials to Start Recognizing Patterns
- Conducting Routine Audits that Include Checking Diagnosis Codes
- Educating Providers on the Importance of Proper Documentation