Specificity in documentation allows for the most accurate ICD-10 code choices. At this time more and more payors are denying medical claims when you use a diagnosis code(s) that are unspecified. Please do whatever you can to use specificity in your code choices such as:
- Joint pain, joint effusion, injury, fractures, sprains, tears, meniscus, cruciate ligament, dislocations, arthritis, cerebral infarction, extremity atherosclerosis, pressures ulcers, cancers, neoplasm, eyes and ears.
- Stages of Healing
- For pressure ulcers, the possible stages are 1 – skin changes limited to persistent focal edema 2 – an abrasion, bister, and partial thickness skin loss involving the dermis and epidermis. 3 – Full thickness skin loss involving damage and necrosis of subcutaneous tissue. 4 – Necrosis of soft tissues through the underlying muscle, tendon, or bone, and unstageable – bed on clinical documentation the sage cannot be determined clinically (i.e.: wound is covered with escharor for ulcers documented as dee tissue injury without evidence of trauma. Is there associated gangrene?
- Weeks in Pregnancy
- Specify the trimester, i.e.: 14 weeks, 0 days
- Episodes of Care
- A-initial encounter, D-subsequent encounter, S-Sequela (late effect)
- Increased Detail and Codes for Patient Accidents, Fractures, etc.
- Routine, delayed, nonunion, malunion
- Tobacco exposure
- Cigarettes, chewing tobacco, E cigarettes and other tobacco products and further break down to uncomplicated, in remission and withdrawal.
- Relief or non-relief
- (Intractable versus non-intractable) especially for headaches and migraines.
- Acute and/or chronic must be included in the patient’s condition.
- Acute tells you’ve been hurt. The pain appears suddenly, peaks as a signal to your body to heal the injury and wanes as it heals. Chronic on the other hand creeps up on you gradually. Back pain that lasts for months and worsens over time is a good example of chronic pain.
With that being said, even CMS explicitly recognizes that unspecified codes are sometimes necessary. Widespread use of unspecified codes should be the exception, not the rule. It is necessary to strive for the highest level of detail in diagnosis coding, as well as accuracy in the use of your code choices. If you code and document to the highest level of specificity it will help prevent medical necessity denials and claim rejections.