Outpatient Facility Coding Alert

Question: I've read a lot of advice that says never to use unspecified codes because they will be denied. But if we're never supposed to use them, why are they still a choice?

Rhode Island Subscriber

Answer: Coders like to think in black and white, so advice like "never do this" and "always do that" is appealing. But like it or not, there are gray areas in coding, and using unspecified codes is one of those areas. "There are legitimate reasons for choosing an unspecified code," says Rhonda Buckholtz, CPC, CPCI, CPMA, CDEO, CRC, CHPSE, COPC, CENTC, CPEDC, CGSC, vice president of practice optimization at Eye Care Leaders.

For example, on a patient's first visit, you may have not clinically determined the actual disease process, or sent or received lab results. Also, the default for some conditions is an unspecified code. "These are situations that might occur in a physician practice, but are much less likely to occur in an ASC," says Buckholtz. Patients come into the ASC for scheduled surgeries, so they've already been evaluated, maybe more than once," she continues.

There is one situation where never really does mean never: cases involving laterality, such as cataract surgery or an Achilles tendon repair. When coding surgical procedures, you should always know which side of the body on which a procedure was performed. If that information is missing from the surgical notes, that's an opportunity for documentation training with that physician.

To clear up confusion around when and when not to use unspecified codes, you can leverage technology. "Consider asking your EHR vendor to remove unspecified laterality codes from your software," advises Buckholtz. For other unspecified codes, you can ask them to add a pop-up alert. "An alert will give your coders one more chance to review whether an unspecified code is really the right choice," she adds.

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