You have be under the impression that you should never utilize unspecified codes.  This is completely incorrect.  Actually, when unspecified codes are used wisely, it can make a significant difference in your ability to get your claims paid.

Before deciding to submit a claim with an Unspecified Code, you should ask yourself the following questions:

“Could my healthcare provider have more information about the case beyond what was documented, and this information allow me to choose a more specific diagnosis code for the claim?

If the answer is yes, then ask yourself:

“Is the additional information I would receive relevant enough that I should ask the provider for more information?” 

Although there are certainly circumstances where utilizing an Unspecific code is legitimate, it does mean your claim will be under greater scrutiny by payers. However, filing the same claim with a more specific diagnosis code means your claim will be less likely to be denied and you’ll be more likely to get paid.

Utilize the examples below to help you decide when it is and isn’t appropriate to submit an unspecified code with your claim:

When Unspecified Codes are ACCEPTABLE:

• Example #1: Your primary care physician has diagnosed a patient with heart failure and refers the patient for an echocardiogram to a cardiology provider within your practice. However, when you get the claim, the patient hasn’t yet been evaluated by the cardiologist and the echocardiogram hasn’t been completed.  Accordingly, until the cardiologist sees the patient and makes a definitive diagnosis, code I50.9 (unspecified heart failure) most accurately describes the patient’s diagnosis.  The patient’s diagnosis may change after more information is received and studies are done, but at this particular encounter, unspecified is appropriate.
• Example #2: A patient has been diagnosed with rheumatoid arthritis, but the rheumatoid factor hasn’t been determined. Accordingly, M05.9 must be used to capture the rheumatoid arthritis with rheumatoid factor, unspecified.
• Example #3: An unconscious patient is found in an alley and brought to the ED by paramedics.  After toxicology screens, it is identified that there has been an opiate overdose. However, since there were no witnesses to the event and the patient is not able to respond, there is no way to determine initially if this is self-harm, an assault, or accidental.  Accordingly, poisoning by an opiate that was undetermined in nature, which is an unspecified cause, would be appropriate; T40.605A.

When Unspecified Codes are UNACCEPTABLE:

• A radiologist looks at a patient’s x-ray and diagnoses a fracture. However, the radiologist fails to provide you with enough information in the documentation to choose the most accurate fracture diagnosis code. This is NOT a case where the fracture diagnosis code, T14.8XXA (injury of an unspecified body region) should be used. Utilizing the unspecified code in this case will undoubted get kicked back. Surely, if the x-rays are of a specific body area, your radiologist should know which area and which bone they viewed, so applying an unspecified code in this instance would be unacceptable.
• A provider identifies that the patient has a complication of surgical or medical care and wants you to apply diagnosis code T88.9XXA .  However, this is not correct, and would most likely get denied for more information.  If your providers identified a complication, surely the reason for the complication can be identified. Accordingly, an unspecified complication code is not appropriate.
• If A patient has an adverse effect to medication. The unspecified adverse effect code (T88.7XXA) would not be appropriate, because the physician should be able to determine what the adverse effect is.
• A patient with burns to body areas or an injury to a limb, should never be submitted with an unspecified code. Your provider should be able to easily determine the specific body area injured (arm or leg, and even more specific is it right or left).  So, you should be able to utilize a much more specific diagnosis code. If not, your claim will most likely be denied. The same is true when applying a diagnosis code for pain. Although the cause of the pain may not be immediately known, the location of the pain should be.   When these types of things are not identified in the patients record, it is often just incomplete documentation, not that the information is unknown.

The underlying lesson is – if the provider should know the answer (even if he didn’t provide it to you) an unspecified code is never the answer.

Although there may be medical conditions that without additional testing and information, the specificity can’t be determined. When this occurs, unspecified codes are the only codes that apply.  You always need to code to the highest level of specificity known and determined. If it isn’t known, it can’t be coded, so there will never be a time that all unspecified codes will be prohibited.

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This valuable content was written by Jennifer Swindle, Vice President of Quality and Service Excellence with Salud Revenue (www.saludrevenue.com).

To contact the author directly please email [email protected]. Or, you may contact Training Leader at 800-767-1181 or [email protected].