Medicare Compliance & Reimbursement - 2015 Issue 11
Reader Question: Not Enough Documentation? Turn to 'Unspecified'
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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.
Why This Topic Matters
Understanding how to handle crosswalk gaps and incomplete documentation helps coding teams support accurate ICD-10 reporting and encourage more complete medical records during the transition from ICD-9.
What You Will Learn
- How ICD-9 to ICD-10 crosswalk differences can affect code selection
- Why ICD-10 may require more detailed provider documentation
- How laterality can affect specificity in ICD-10 reporting
- The general difference between broad and unspecified ICD-10 options
Who Should Read This
- Medical coders
- Coding auditors
- Documentation improvement specialists
- Healthcare providers
- Compliance staff
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