Unspecified DX Codes

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Does anyone have a tried and true method to determine if an unspecified dx code can be coded to more specificity? Or is it all subjective to notes available, etc?
 

mitchellde

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Sometimes unspecified is the best you can do because it is the best the provider can do. Ask yourself, given the information available to the provider, is there anyway he could or should be more specific at this encounter. Like anemia, the provider can see by a STAT H&H and presenting symptoms that the patient has anemia, however is there anyway to know what type of anemia? Probably not so unspecified anemia is the best possible choice.
 
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Sometimes unspecified is the best you can do because it is the best the provider can do. Ask yourself, given the information available to the provider, is there anyway he could or should be more specific at this encounter. Like anemia, the provider can see by a STAT H&H and presenting symptoms that the patient has anemia, however is there anyway to know what type of anemia? Probably not so unspecified anemia is the best possible choice.
thank you! I am working through a list of unspecified codes and trying to determine if they "could" be more specific. For example, J06.9, acute upper respiratory infection, unspecified.
 

dneiman

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thank you! I am working through a list of unspecified codes and trying to determine if they "could" be more specific. For example, J06.9, acute upper respiratory infection, unspecified.
We have run into the same thing at our office. For that particular code (J06.9), we have found J39.8 "Other specified diseases of upper respiratory tract" works.
 

Tonyj

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We have run into the same thing at our office. For that particular code (J06.9), we have found J39.8 "Other specified diseases of upper respiratory tract" works.
I'm curious as to how you came up with J39.8 "other specified diseases of upper respiratory tract"?
If the documentation doesn't state a specified disease how is it other specified?
As Debra stated and to reiterate, there are numerous times when unspecified is the best if not only option.
 
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