NWCA Medical Billing and Coding Practice Exam

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Under what circumstances is an unspecified ICD-10-CM code acceptable?

When the documentation lacks sufficient detail to support a more specific code and the condition is reported

When you forgot to code

When you want to avoid specificity

When the documentation lacks detail to support a more specific code and the condition is reported

Use of an unspecified ICD-10-CM code is allowed only when the documentation does not provide enough detail to support a more specific code and the condition is being reported. This reflects the need to accurately capture what is documented while avoiding misrepresentation; you should not pick unspecified just to save time or because you prefer less detail, and you should not skip coding or pretend more detail exists. If the record does have enough detail to support a specific code, you should assign that specific code instead.