Payers look for claims to contain highly specific codes to support any medical necessity of a procedure or service performed in healthcare. Getting paid for “unspecified” diagnoses may be as difficult as getting paid for “unlisted” procedure CPT codes; and overuse of unspecified ICD-10 codes may subject the provider to audits.
The ICD-10 code set contains enough specificity and granularity that using an unspecified code should be your last resort. Think of unspecified ICD-10 codes just as you would unlisted procedure codes in CPT. You should use an unlisted code ONLY if a specific code for the procedure does not exist.
Unspecified code exists for a few reasons, some good and some not. A coder may resort to using unspecified codes when:
- Documentation is insufficient.
- Documentation isn’t accessible at the time of reporting.
- Billing sheet has overabundance of unspecified codes.
- The biller failing to update themselves on codes and relying on what is committed to memory.