Use of Additional Code for Condition of Unspecified Type
Coding Clinic Second Quarter 2021 addresses “unspecified” codes stating that “facilities may develop internal facility-specific coding policies, stipulating whether to report “unspecified” codes as additional codes, when more specific information is not documented and the unspecified code does not add any useful information.”1
The example is for an obstetrical record in which the physician documents that the patient is an obese woman at 40 weeks that delivers a normal healthy baby. Code O99.214, obesity complicating childbirth, is assigned. In the Tabular List under code O99.214 are the directions to “Use additional code to identify the type of obesity (E66.-)”. Since the record does not specify the type of obesity and code O99.214, Obesity complicating childbirth, fully captures the diagnostic statement, coding E66.9 does not add any useful information and is not needed as an additional code because “unspecified” is not a type of obesity and E66.9 does not provide additional information.
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1. AHA Coding Clinic Second Quarter 2021