External Cause Codes
There is no national requirement for mandatory ICD-10-CM external cause code reporting , just as with ICD-9-CM. Reporting of ICD-10-CM codes in Chapter 20, External Causes of Morbidity, is not required unless a provider is subject to a state-based external cause code reporting mandate or these codes are required by a particular payer. In the absence of a mandatory reporting requirement, providers are encouraged to voluntarily report external cause codes, as they provide valuable data for injury research and evaluation of injury prevention strategies.
Sign/Symptom/Unspecified Codes
In both ICD-9-CM and ICD-10-CM, sign/symptom and ?unspecified? codes have acceptable, even necessary uses. There are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter, while specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient?s health condition. Each healthcare 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. It is acceptable to report the appropriate ?unspecified? code (e.g., a diagnosis of pneumonia has been determined, but not the specific type) when sufficient clinical information isn?t known or available about a particular health condition to assign a more specific code. In fact, unspecified codes should be reported when they are the codes that most accurately reflects 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 conduct medically unnecessary diagnostic testing in order to determine a more specific code.