229 As we approach October 1, 2013, and the last scheduled year of reporting diagnoses with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), there remains a good deal of misinformation about the soon to be adopted International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code set. Often when ICD-10-CM is discussed, it is noted that unspecified codes may be denied when reporting diagnoses with ICD-10-CM. Likewise, it has been noted that the abun- dance of external cause codes available to describe circumstances related to injuries and conditions will greatly increase the number of codes reported. A statement released by the 4 cooperating parties (American Health Information Management Association, American Hospital Association, Centers for Medicare & Medicaid Services, National Center for Health Statistics) for ICD-10-CM/PCS (PCS is the inpatient procedural por- tion of ICD-10-CM) and ICD-9-CM in May 2013 offers important clarification on these topics. The statement, which can be found online at http://library.ahima.org/xpedio /groups/public/documents/government/bok1_050189.hcsp?dDocName=bok1_050189, should resolve some confusion and concerns about adoption of ICD-10-CM. This article will focus on the clarifications of use of unspecified codes and codes for signs and symptoms. Clarification of external cause code use will be reviewed in a future issue of AAP Pediatric Coding Newsletter™. The cooperating parties clearly state that unspecified codes have acceptable, even neces- sary uses. An unspecified code or codes for signs and symptoms may be reported when it would be inappropriate to assign a specific code not supported by medical record doc- umentation or when unnecessary diagnostic testing would determine a more specific code. Any reporting would need to be based on the information available in medical record documentation. Following are guidelines for reporting an unspecified code or signs and symptoms: Codes should reflect what is known about the patient’s condition at the time of the encounter. If no definitive diagnosis is determined at an encounter, codes for signs and symptoms should be reported. It is appropriate to report an unspecified code when clinical information is not known or not available for a diagnosed condition. For those categories for which an unspecified code is not provided, the “other specified” code may represent other and unspecified. When documentation lacks information that was likely known at the time of the encounter (eg, laterality), it is appropriate for a coder to query the physician or provider for additional information to determine if a specific code may be assigned based on an addendum to the record. Appendix B-3 Important ICD-10-CM Clarification: Use of Unspecified Codes (continued on page 230)
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