Payers look for claims to contain highly specific codes to support any medical necessity of a procedure or service performed in healthcare. Getting paid for “unspecified” diagnoses may be as difficult as getting paid for “unlisted” procedure CPT codes; and overuse of unspecified ICD-10 codes may subject the provider to audits.

The ICD-10 code set contains enough specificity and granularity that using an unspecified code should be your last resort. Think of unspecified ICD-10 codes just as you would unlisted procedure codes in CPT. You should use an unlisted code ONLY if a specific code for the procedure does not exist.

Unspecified code exists for a few reasons, some good and some not. A coder may resort to using unspecified codes when:

  1. Documentation is insufficient.
  2. Documentation isn’t accessible at the time of reporting.
  3. Billing sheet has overabundance of unspecified codes.
  4. The biller failing to update themselves on codes and relying on what is committed to memory.