Anesthesia Coding Alert

Question: What is the difference between "unspecified" and "uncertain" nature of problems?

Idaho Subscriber

Answer: Many coders go by the rule of thumb that "unspecified" means you don't have the information given to you and that "uncertain" means the physician doesn't know how the patient's problem will manifest. Unspecified nature applies when you're prescheduling the patient's surgery or anesthesia visit and you don't have a pathology report, unless you have information that the neoplasm is malignant or benign. Most physicians define uncertain behavior as a premalignant or villous adenoma or any lesion or neoplasm that is questionable, even with a pathology report.