Physicians and Coders: No More Unspecified Care

Barbara Aubry, a regulatory analyst for 3M Health Information Systems, contributed this blog.

The team I work with has done an enormous amount of work translating medical necessity policies from ICD-9 to ICD-10. And we have had many discussions regarding the codes that represent “unspecified” care in ICD-10. Should they stay in the translations – or go? Is ICD-10 specific enough to cover all care and coding contingencies now?

Unspecified Defined

An internet search (don’t you love being able to search so easily?) revealed:

Un-spec-i-fied: (adjective) meaning “not stated clearly or exactly”. Synonyms: unnamed, unstated, unidentified, undesignated, undefined, unfixed, undecided, undetermined, uncertain…

I don’t know about you, but when I was in nursing school none of the synonyms above were expected to represent how I was taught to create clinical documentation. And my medical colleague’s in training – if documentation training in med school is anything like nursing – were not taught to document this way either. I don’t know any clinical professional who would want their documentation referred to in any of the terms above – for a host of reasons.

I recently read a study (Accuracy & Completeness of Clinical Documentation) that was performed in the United Kingdom. It found that clinician’s spent 50% (or more) of their time in the documentation process. This report can be interpreted in several ways, but for the purpose of this blog, I’m going to choose two:

  1. By using EHRs, the physicians are forced to complete documentation required to more accurately represent the clinical encounter – and it’s taking more time – perhaps due to their computer documentation skills
  2. Prior to EHR use, provider’s documentation was so substandard that it took little time

But before EHRs, we seemed to muddle through somehow. It was more the responsibility of the reader to decipher the clinical note(s) and many unscientific methods were used. Now, with the focus on value-based reimbursement and the digitizing of health care, there is a lot more at stake.

Correct Use of Sign/Symptom/Unspecified Codes

Codes titled “unspecified” can be used when the information in the medical record is insufficient to assign a more specific code. For those categories for which an unspecified code is not provided, the “other specified” code may represent both other and unspecified (see Section I.B.18 Use of Signs/Symptom/Unspecified Codes). This however, does not give providers permission to use unspecified codes when the necessary information can be obtained and documented.

Sign/symptom and “unspecified” codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter.

If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient’s condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.

Clinical Example of Correct Use of Unspecified Code

Provider has an initial visit with a new patient who reports that she has a fracture of her vertebra. She is not sure which level was actually impacted. Her knowledge of the location of the fracture is limited to “my lower back.” In this instance, the physician would accurately report a code for a vertebral fracture, unspecified level and unspecified type.

Of course one would hope that at later encounters he has been able to access additional medical records to be able to determine which level of vertebra was actually fractured – and the type. In subsequent claims, it would be acceptable to expect a more specific diagnosis for this same patient. It is not suggested to use unspecified codes on a regular basis. Why? If you were a payer, would you be watching those providers who use the codes frequently? Of course you would – and that behavior pattern is begging for an audit.

Payer Reactions to Unspecified Codes

I hope I’ve established my position on the use of unspecified codes; they are appropriate in certain situations. You might be interested in what payers are saying – perhaps it will help you determine how you will use them.


“In both ICD-9-CM and ICD-10-CM, sign/symptom and unspecified codes have acceptable, even necessary, uses. While you should report specific diagnosis codes when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, in some instances signs/ symptoms or unspecified codes are the best choice to accurately reflect the health care encounter. You should code each health care encounter to the level of certainty known for that encounter. It is inappropriate to select a specific code that is not supported by the medical record documentation or to conduct medically unnecessary diagnostic testing to determine a more specific code.”

Wellmark (BCBS)

Q1. Will Wellmark change medical necessity requirements because more specific codes will be available?

A1. No. Wellmark is not changing the intent of any of our medical policies due to ICD-10.

Q9. Will Wellmark reject unspecified codes?

A9. No. However, unspecified codes may have a negative impact on inpatient reimbursement. The lack of specificity may impact the DRG or severity of illness

Final Thoughts

I hope you decide to ramp up your documentation so no one can say yours is any of the “un” synonyms above. Use the unspecified designation carefully and when necessary. Assume payers are looking for those outliers who use unspecified codes frequently. And don’t forget that CMS is in the act of matching POS (place of service) codes on professional claims to facility services. You absolutely want the ICD-10 diagnosis codes on the professional claim to be in sync with the diagnosis codes on the facility claim. I know what you are thinking – but you can do this.

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