We have been receiving a number of calls and emails and
coding questions regarding the “discontinued” use of all unspecified codes
after October 1st, 2016.
Many entities are incorrectly or inaccurately reporting that CMS and
commercial carriers will no longer
accept any unspecified codes after October 1, 2016. We have also had
clients attend webinars where the lecturer told attendees not to use any ICD-10 codes ending in 0 or 9.
Here is some information to clarify any confusion and set
you along a straighter path.
First, the information is only partially true, but it’s not an absolute rule. It appears that
the authors of these articles or presenters giving these webinars clearly don't
understand ICD-10... and are frankly offering erroneous and bad advice.
Here is the correct information...
CMS and commercial carriers want
you to avoid the use of unspecified
codes, if at all possible. But sometimes this isn’t possible and sometimes the
use of an unspecified code is perfectly acceptable and payable.
First, CMS states that the use of unspecified codes is acceptable when, based on all
clinical knowledge at the time of the encounter, the provider can't specify an
Here is an ICD-10 Myths and Facts Bulletin (See page 2)
“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 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.
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 is not known or available about a particular
health condition to assign a more specific code, it is acceptable to report
the appropriate unspecified code (for example, a diagnosis of pneumonia has
been determined but the specific type has not been determined). In fact,
you should report unspecified codes when such codes most accurately reflect
what is known about the patient’s condition at the time of that particular
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.
CMS also released some clarification FAQs on the use of
unspecified codes and the end of the grace period.
See questions 27
Question 27: (new
08/18/2016) Will unspecified codes be allowed once ICD-10 flexibilities expire?
Answer 27: Yes. In
ICD-10-CM, unspecified codes have acceptable, even necessary, uses. Information
about unspecified codes, including an MLN Matters article and videos, can be
found on the CMS website. 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. When sufficient clinical information is not known or
available about a particular health condition to assign a more specific code,
it is acceptable to report the appropriate unspecified code (for example, a
diagnosis of pneumonia has been determined but the specific type has not been
What they are really trying to say…
The first issue centers around site-specific ICD-10 codes. If
there are site-specific ICD-10 code choices (e.g., trunk, face, left lower
extremity, etc.) those codes should be used instead of an unspecified body site.
In other words, you don't want to use codes for Basal Cell Carcinoma, unspecified
parts of face (C44.310), when you should be using BCC of nose (C44.311) or
BCC other parts of face (C44.319).
The same is true for ICD-10 codes where left vs. right, or
upper vs. lower, choice exists. Again, don’t default to "unspecified"
codes when site-specific or laterality-specific choices exist. Dermatology is a
visual specialty and there is no excuse not to document where, and left vs.
right, or upper or lower, etc.
Sometimes, based on what is known at the time of the
encounter the provider has to use an unspecified code because not enough
clinical information is known. For example, the patient may have dermatitis,
but the provider cannot determine a cause. The use of an unspecified dermatitis
code is appropriate here.
all codes ending in ‘0’ or ‘9’ are unspecified
It is not true that all unspecified codes end in a ‘0’ or ‘9’.
In the previous example, Basal Cell Carcinoma of “other
parts of face” is C44.319, and happens to end in a '9'. C44.319 is a specific
payable ICD-10 code.
Here’s another example. You don't want to use Allergic
Dermatitis of unspecified eyelid (when you should know to code either the upper
or lower, or left vs. right).
Let’s look at Actinic Keratoses. The ICD-10 code is L57.0. This
code happens to end in a ‘0’. It’s a specific payable ICD-10 code for CPT
Here are some other examples of ‘specific’ ICD-10 codes
ending in ‘0’ or ‘9’
L10.89 - Pemphigus, other
L60.0 - Ingrown Nail
C4A.0 - Merkel Cell Carcinoma of the Lip
all unspecified codes end in ‘0’ or ‘9’
Look at these ICD-10 codes. They are ‘unspecified’ but don’t
end in a ‘0’ or a ‘9’!
L25.3 - Unspecified contact dermatitis due to other chemical
H61.001 - Unspecified perichondritis of right external ear
D49.2 - Neoplasm of unspecified behavior of bone, soft
tissue, and skin
use of “other” versus “unspecified”
Often, you will see that an ICD-10 code series offers “other”
as one of the code choices. If the condition you are coding doesn’t fall into
one of the specific ICD-10 codes listed, and an ‘other’ code exists, default to
the ‘other’ code instead of the unspecified code.
Example 1 - If the patient has psoriasis, and it’s not one of the types listed
in L40.0-L40.5, default to ‘other psoriasis’ (L40.8) instead of psoriasis, unspecified
L40.0 - Psoriasis vulgaris
L40.1 - Generalized pustular psoriasis
L40.3 - Pustulosis
palmaris et plantaris
L40.4 - Guttate
L40.5 - Arthropathic
L40.8* - Other psoriasis
L40.9 - Psoriasis,
Example 2 - Basal cell carcinoma of the cheek. Here are your choices…
C44.310 - Basal cell
carcinoma of skin of unspecified parts of face
C44.311 - Basal cell
carcinoma of skin of nose
C44.319 - Basal cell
carcinoma of skin of other parts of face
It’s not the nose, so choose “other parts of face” (C44.319).
Don’t use the unspecified code!
the carrier’s LCDs or medical payment policies
Lastly, check your Medicare LCDs or carrier medical policies.
These will usually list the covered ICD-10 codes for certain CPT codes where an
LCD or medical policy exists.
Here is the “Removal of Benign Skin lesions” LCD for
Michigan Medicare for CPT code 17110. You will see reference to B07.9 (Viral
Wart unspecified) as a covered ICD-10 code.
And here is an Aetna Phototherapy and Photochemotherapy
(PUVA) for Skin Conditions policy showing unspecified contact dermatitis,
unspecified cause as a covered ICD-10 code for UVA/UVB light therapy.
We highly recommend you purchase our 2017 ICD-10 for Dermatology,
which includes a 1-hour derm-specific webinar, an update for all of the changes
affecting dermatology, plus great dermatology-specific training and examples. I
also go over the 50 most common dermatology questions we've received and ICD-10
pitfalls. It's been our best seller the past 3 years and we just updated it for
all the changes effective October 1st 2016 and for next year!