Unspecified vs 'Other specified" Codes

rnewsomecpc

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I am in a quandary right now. I was taught that you do not code anything that is not documented in the encounter note. (except chronic conditions etc that have been established and are under ongoing treatment). With this being said, the office I worked for was getting a lot of kickback for using the 'unspecified' codes (ex: D51.9, E78.00 etc.) and as a result they wanted to use the other specified codes (D51.8 vs D51.9).

My question is - can we do that? Here is an example:

PT comes in for a B12 shot for "Vitamin b12 def, unspecified" (word for word) as noted on the encounter. We were told to bill as "other specified B12 def" as this would pay and the other would not. Usually I would query the physician for a more accurate diagnosis but a lot of the time there WAS no more specific diagnosis, especially in these cases. Also, asking them to go back and change their diagnosis so we could bill and get paid seemed unethical. This isn't a case of there being a more accurate diagnosis available, but changing the diagnosis on the claim.

I am relatively new, so I am curious as to whether we could do this. I refused to until I got clarification but I haven't found any specific documentation on it. Can someone help me out or point me in the right direction? Thank you!
 

thomas7331

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You are correct - if the type of B12 deficiency (or any other disease) is not specified in the documentation, it would be incorrect coding to use a code that states 'other specified'. The official guidelines for ICD-10 diagnosis coding, section I A.9 (at the beginning of the book) is very clear about this: "Codes titled "other" or "other specified" are for use when the information in the medical record provides detail for which a specific code does not exist.... Codes titled "unspecified" are for use when the information in the medical record is insufficient to assign a more specific code." The two are not interchangeable. I do agree it would be unethical do change these codes for payment purposes if the documentation does not support it.
 
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