The Complexities of Unspecified ICD Codes - SybridMD
Unspecified ICD Codes

What Are “Unspecified ICDs” And What Are The Complexities Of Their Use

What is ICD?

International; classification of diseases (ICD) is a system used by physicians and health care providers to classify diseases. It is used to classify and code all diagnosis, symptoms, and procedures recorded in conjunction with clinical care, hospitals, and other healthcare facilities.

ICD is based on the international classification of diseases. It uses unique alphanumeric codes to do the identification of known diseases and other health care issues.

Physicians, medical billing coders, physicians, insurance companies and other healthcare specialists use ICD codes to document diagnostic data. ICD records are now also used in population health management and big data handlers can easily retrieve statistics of national mortality and morbidity facts & figures.

ICD is increasingly used in clinical care and research to define diseases and study disease patterns for a population. World Health Organization (WHO)  develops and publishes new updates of ICD codes which are then customized by different countries according to their needs. With the help of ICD codes, patient information can be shared across through integrated EHR systems. ICD provides a better mapping of clinical procedures and the coding system is widely used to capture the clinical data and care procedures.

What does unspecified mean in medical terms?

According to the National Association of Rural Health Clinics (NARHC), unspecified ICDs are defined as, coding that does not fully define important parameters of a patient’s condition. In other words, it could be defined as, ‘coding that does not fully define important parameters of the patient condition’.

However, unspecified ICDs have raised lots of questions, such as, that it might lead to wrong diagnostic procedures or it might lead to denial of claims. It is true that ICD should be specific as much possible as it can be, however, it can cause various anomalies.

Most of the discussions that revolve around the unspecified ICDs, don’t really grasp the real meaning of “unspecified”. Unspecified codes are actually ICD codes that do not completely identify the diagnostic procedures. For example, unspecified ICD codes do not indicate lateral anatomical aspects like right, left, multilateral injuries or other conditions. Most unspecified codes simply state the diagnosis and contain the word “unspecified” within their description.

Where unspecified ICDs are required?

It is important to know that codes are not only used for coding the clinical procedures, but ICD codes also are part of the payment claim as well and are used o share the clinical information with third parties that are not part of the care process. Mostly, only specific ICD codes are used if there is sufficient evidence to support the documentation of the health status of the patient. There are several cases where there is inadequate coding information regarding a clinical procedure and the use of “unspecified codes” is the alternative to accurately reflect a patient’s applied procedures. If no specific diagnosis is made at the end of the encounter, the use of unspecified codes becomes a necessity.

Physicians are required to include the symptoms/signs that you think are indicative of a particular condition instead of stating the condition immediately. For example, a physician has diagnosed that a patient has typhoid, but he cannot comment on the specific type of condition at that time. Assigning a particular code if there is not enough information in the medical record documentation or performing unnecessary medical tests to commit to a specific code can lead to rejections.

Situations to use unspecified ICDs:

When and in what conditions the ICDs fall under “unspecified”.

There are always clinical visits of patients when there is really hard to specify the disease exactly through ICDs. Following are the situations in which unspecified ICDs are accepted.

  • When the clinician is not clear enough about the condition of the patient. Because the evaluation is still in the early stage. In such a situation, the clinician cannot use a more accurate and specific code.

Suppose a patient visits a doctor after a minor accident and reports the knee sprain in his right leg. In this particular case, the physician has no detailed information about the condition of the patient and he continues to instruct him to perform various tests and x-rays of the knee. At this time, it makes more sense for the doctor to use the “unspecified code” instead of guessing that the patient has a specific diagnosis. The correct code could be S83.91XA. sprain of unspecified site of the right knee, initial encounter.

  • When the provider is not specifically sure about the diagnosis the use of unspecified ICD codes becomes a necessity. Keep in mind that using certain codes, if there is not enough support documentation, can lead to information being both unreliable and invalid, it means diagnosing a patient with a condition that may not reflect the true condition. Therefore, the accurate use of ICD codes requires expertise.
  • Most of the clinical staff have no expertise in transcribing the diseases in codes. Therefore, physicians seek services of medical billing and coding experts.

Importance of unspecified ICDs:

Why cannot coders provide more accurate codes for all the medical conditions? When there is a probability that the use of unspecified codes may lead to wrong diagnoses. An inaccurate diagnose of a patient can affect and compromise not only the quality of provided health care treatment but also the medical records of the patient. Unspecified codes are to use when the information in the medical record is insufficient to assign more specific codes. That’s why it is better to use unspecified ICDs in situations when there is uncertainty. Specific codes should only be used when there is enough evidence to support documentation of a patient’s health conditions.

What are other specified codes?

Codes marked “Other Specified” or ” not elsewhere classified (NEC)” in the title are used when the information in the medical record contains details about a code that is not present in ICD data.

Unspecified code often referred to as “not otherwise specified (NOS)”, differs from an “NEC” code. An unspecified code is used if the medical record is insufficient to assign a more specific code. The provider does not have enough information yet. If the provider chooses an unspecified code, then the provider has to inform the payer that they do not know enough about the condition of the patient to provide documentation that supports a more specific diagnosis. This should be stated as the exception instead of a rule. There may be situations where the provider is waiting for the lab results and is therefore forced to use an unspecified or “NOS” diagnostic code. Once this information is available, however, a more specific diagnosis should be assigned.

The specificity of unspecified codes

Providers must report the most accurate diagnostic codes available at the time of service. If a provider is unable to provide the most detailed level of specificity at the time of the patient, an unspecified diagnostic code may be used. However, providers should be aware that possibly unspecified diagnostic codes are displayed during the complaint decision, and requires the provider to provide documentation to justify the unspecified codes. Suppliers/programmers/ billers are strongly encouraged to contact the payer to set their specific policy regarding unspecified codes. It should also be noted that the coding of the symptoms the patient has (as opposed to the diagnosis) is also acceptable in some limited cases.

Medical billing & coding professionals have the knowledge and resources to support coding initiatives and techniques. Medical coding specialists should continue to educate providers about the importance of clear and complete documentation for proper and specific ICD coding. Persistently good habits and detailed documented practices will help to reduce anomalies. Constant collaboration between providers and developers of the coding systems can help to decrease the irregularities over time.

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