ICD-10 Basics: Unspecified Diagnosis Codes, CPT Codes, and Version 5010 Standards

News Updates | June 26, 2014

ICD-10 Basics: Unspecified Diagnosis Codes, CPT Codes, and Version 5010 Standards

The Department of Health & Human Services (HHS) expects to release a final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning October 1, 2015. The new compliance date would give providers an extra year to prepare. Now is a great time to brush up on ICD-10 basics as you get ready for the transition.

If you missed the June 4 MLN Connects National Provider Call, More ICD-10 Coding Basics, a written transcript and audio recording are now available.

And for a quick refresher on a few ICD-10 basics where the Centers for Medicare & Medicaid Services (CMS) frequently receives questions, read on!

Unspecified Diagnosis Codes
In both ICD-9 and ICD-10, sign/symptom and “unspecified” diagnosis codes have acceptable, even necessary, uses.  While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the health care encounter. Each health care encounter should be coded to the level of certainty known for that encounter.

If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). In fact, unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient’s condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or to conduct medically unnecessary diagnostic testing in order to determine a more specific code.

CPT Codes
The transition to ICD-10 does not affect Current Procedural Terminology (CPT) coding for outpatient procedures.  Like ICD-9 procedure codes, ICD-10 procedure codes (ICD-10-PCS) are for hospital inpatient procedures only.

Version 5010
You must be using Version 5010 HIPAA standards in order to conduct electronic transactions with ICD-10. The earlier, Version 4010 HIPAA standards cannot accommodate the longer ICD-10 codes. 

Most organizations began using Version 5010 in 2012, when compliance became mandatory under HIPAA. Any providers or organizations still using Version 4010 for electronic transactions are in violation of HIPAA.

If you are not certain whether you are Version 5010-compliant, check with your health IT professional or your clearinghouse or billing service.

Find Out More About the Basics in the Road to 10
To find out more about ICD-10 basics and beyond—including how to build an action plan, update your processes, and test your readiness—check out the Road to 10 resource for small medical practices, available at cms.gov/ICD-10.

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This service is provided to you by the Office of E-Health Standards & Services, ICD-10.