Be Specific - Even When the Provider Is Not

Often times we find that some providers are not very specific in their diagnoses documentation.  This has always been a concern, however with ICD-10 implementation, specificity has never been more important.  Payers have stated that they will be more lax during the first year of ICD-10 implementation and allow for more non-specific codes.  However, in the years coming, this relaxed policy is sure to change.  That is where coders come in. 


Have you ever seen a provider diagnose abdominal pain without specific reference to a location within the abdomen?  I am certain we all have.  Most often, the provider does in fact document an exact location somewhere else in the documentation.  We must always thoroughly review the documentation to find this specific location, capture it and utilize it in the final code assignment.  Because abdominal pain is a “symptoms code”, the specific location can be taken from the history of present illness, review of systems, or exam. 

Another example is fracture diagnoses.  Often, providers will state a non-specific fracture like a distal radius fracture without further specification.  Thankfully providers will often refer to, and import the x-ray which clearly shows the fracture to be of the styloid process which can be coded instead. 

Coding an encounter can seem like a treasure hunt, but the prize at the end is so worth it.  Being as specific as possible leads to clean and faster claims processing, and in the future, help avoid denials.  On top of that, these examples are also great education points for providers to help them improve their documentation.  


Mindy Harris

Director Of Coding Quality And Assessment for Healthcare Resource Group, Inc. 


Mindy Harris, CCS, CPC, CPMA has over twenty years of healthcare experience in coding, auditing, clinical documentation improvement, compliance, staff development and education. Mindy, an approved AHIMA ICD-10-CM-PCS Trainer, is an experienced educator, team leader and director of professional fee and both inpatient and outpatient facility coding. Mindy strives and succeeds at keeping quality and accuracy above industry standards for HRG and their team of coding professionals. 


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