by Cheryl Nash
2025 is the 10th year anniversary for ICD10 and yet I am still amazed at how many claims I review with an unspecified diagnosis code. The premise of an expanded code set was to allow for more specificity in diagnosis selection and most EHR’s have the entire database integrated into their system. So why, then, are providers selecting non-specific codes? My suspicion is because of automated coding suggestions.
The Scenario-
You, the provider, look for the patient’s condition in a search tab. You try to be exact, but there are sometimes hundreds of options to choose from and you have another patient (sometimes several) waiting, so you select the first one that looks appropriate because, quite honestly, you don’t have time to review the 3rd page in the list, right?! Sadly, those first codes tend to be the non-specified ICD10s.
From a claims standpoint it’s a persistent issue causing denials that prompt medical record requests and ultimately delaying processing. If the chart note also reflects the non-specific diagnosis the delay could be even longer, subjecting your billing team to submitting claim corrections, multiple calls and appeals, potentially dragging things out for months. Costly indeed!
Here’s a common example-
In the peripheral vascular world proper coding selection includes laterality, condition specific complications, and specific location(s).
Often, we see the code L97.909, Non-pressure chronic ulcer of unspecified part of unspecified lower leg with unspecified severity. The payer expects that if you are diagnosing an ulcer, you at least looked at it! And should therefore know where it is and how deep it is. At first pass this appears to be a daunting task. There are over 150 codes in this range to select from, detailing that the ulcer is on the (RT, LT) leg, in the (thigh, calf, ankle, foot, other) with breakdown of (skin, fat, muscle, bone) with or without necrosis. Likewise, if you are coding a condition with a complication, such as Varicose veins with ulcer of lower extremity, this should also include RT or LT and location as noted above.
The Solution-
The first line of defense is always a good offense. Most EHR’s have a Favorites option. Take a bit of time and set this up so the most often used ICD10s are the first to pop-up. An additional step could be to assign the more complex coding to a trusted team member for review. They would identify the proper code(s) and append them to the e-superbill and then the physician can do a final approval before signing the note. Reach out to your EHR support desk to ask what other workflow solutions they may have available to you. And, of course, there is always the good old-fashioned option of just taking a couple extra minutes out of your day to select the most specific code(s) to match the notes in the patient’s chart.