CHAPTERS

CHAPTER THREE

Specificity

Code to the Highest Degree​ of Specificity Possible

  • Specificity is a core principle of diagnosis coding. The more clinically relevant detail and specificity you can provide, the better.​
  • It’s your responsibility as the treating clinician to code to the highest degree of specificity possible. This gives the payer a full picture of the patient’s condition and helps ensure your patients get timely and appropriate care.​
  • There are two questions to answer to ensure specificity:​

Have you picked the code with the highest number of digits available in the category?
 

Example: In this family of codes for conductive hearing loss, the highlighted codes are billable because they are carried out to the highest number of digits available within each specific category or subcategory.

 

H90 Conductive and sensorineural hearing loss

       H90.0 Conductive hearing loss, bilateral
       H90.1  Conductive hearing loss, unilateral with unrestricted hearing on the contralteral side
                  H90.11 Conductive hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side
                  H90.12 Conductive hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side
       H90.2  Conductive hearing loss, unspecified
 

CODING TIP

It doesn't matter how many digits are in the billable code, only that code is not further subdivided into more specific codes with more digits.

Have you coded to the highest degree of certainty possible? In other words, have you picked the code that is most descriptive of the reason for the visit?
 

Example: Looking at the same family of codes for conductive hearing loss, the highlighted code is billable, but it's not as clinically specific as the other codes in the family. Avoid codes with terms like "unspecified" or "not otherwise specified (NOS)" unless the clinical and medical information you have isn't enough to assign a more specific diagnosis.

 

H90 Conductive and sensorineural hearing loss

       H90.0 Conductive hearing loss, bilateral
       H90.1  Conductive hearing loss, unilateral with unrestricted hearing on the contralteral side
                  H90.11 Conductive hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side
                  H90.12 Conductive hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side
       H90.2  Conductive hearing loss, unspecified
 
CODING TIP

A physician may include a less specific diagnosis, like H90.2, on a referral for audiologic testing. As the qualified health care professional, you can change this diagnosis once you see the patient and have gathered enough medical, clinical, and diagnostic information to code to a higher degree of certainty and specificity.

CHECK YOUR UNDERSTANDING

Take a look at this family of ICD-10-CM codes for sensorineural hearing loss.

 

H90 Conductive and sensorineural hearing loss

        H90.3  Sensorineural hearing loss, bilateral
        H90.4  Sensorineural hearing loss, unilateral with unrestricted hearing on the contralteral side
                    H90.41 Sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side
                    H90.42 Sensorineural hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side
        H90.5  Unspecified sensorineural hearing loss, unspecified
 
Which are the billable code(s) in this family?
CORRECT

Nice Job! H90.3, H90.41 H90.42, and H90.5 are all billable because each code is carried out to the highest number of digits available within each specific category or subcategory.​

INCORRECT

You almost got it! Although H90.41 and H90.42 are billable, they are not the only billable codes within the family. The correct answer is H90.3, H90.41 H90.42, and H90.5 because they’re each carried out to the highest number of digits possible and aren’t divided into more codes.​

INCORRECT

No, that’s not quite it. Although H90.3 and H90.5 are billable, H90.4 is not because there are more specific codes to choose from within that category. The correct answer is H90.3, H90.41 H90.42, and H90.5 because they’re each carried out to the highest number of digits possible and aren’t divided into more codes.​

Using the same family of ICD-10-CM codes for sensorineural hearing loss, let's think about clinical certainty.

 

H90 Conductive and sensorineural hearing loss

        H90.3  Sensorineural hearing loss, bilateral
        H90.4  Sensorineural hearing loss, unilateral with unrestricted hearing on the contralteral side
                    H90.41 Sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side
                    H90.42 Sensorineural hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side
        H90.5  Unspecified sensorineural hearing loss, unspecified
Can you identify the most clinically specific code(s) in the list?
CORRECT

You got it! Of this family of codes, H90.3, H90.41, and H90.42 provide the most detail about the sensorineural hearing loss.

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INCORRECT

No, that's not it. Although it's billable, H90.5 is an "unspecified" code, meaning it s not as clinically specific. The correct answer is H90.3, H90.41, and H90.2 because they provide the most detail about the sensorineural hearing loss.​

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