Reader Question: Not Enough Documentation? Turn to 'Unspecified'

Article Overview

This short Q&A article addresses a common ICD-9 to ICD-10 transition concern for coders and documentation staff: what to do when a familiar ICD-9 code does not map cleanly to a single ICD-10 code. It discusses the need for stronger provider documentation, the role of laterality and other added ICD-10 specificity, and the general distinction between broad category options in ICD-10 when the record does or does not support more detail. The article is relevant to coding professionals, compliance staff, and providers working on documentation improvement.