Coding Diagnoses to the Highest Specificity
Coding specificity is a shared responsibility between the provider and the coding professional. As a medical coder, it is important to code to the highest level of specificity. This is a requirement for all medical coders. For example, if documentation states that a patient’s final diagnosis is myalgia – unspecified, but the history of present illness provides the anatomical site of the myalgia, the coder should assign the most specific code, using all pertinent documentation available in the note. Often, medical claims are denied by payers due to lack of specificity. To ensure that facilities avoid unnecessary denials, it is imperative to remember this rule of thumb about reporting diagnoses to the highest level of specificity supported by the documentation.
Q: A 25-year-old woman presents to the ED with complaints of lower abdominal pain on the left side of the body. She also has nausea but no vomiting. Her last menses was two weeks ago and normal. The provider orders a urine test, which results in negative status for pregnancy. The provider also orders a CT scan to evaluate the abdominal pain; however, the results are negative for a cause of the abdominal pain. Final impression: abdominal pain, unspecified.
A: R10.32, left lower quadrant pain
Reference: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 Section I.B.2.
