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Diagnosis Coding: Using the ICD-10-CM

Use of Sign or Symptom & Unspecified Codes

Sign or symptom and unspecified codes have acceptable, even necessary, uses in ICD-10-CM.

Report specific diagnosis codes when they’re supported by available medical record documentation and clinical knowledge of the patient’s health condition. In some instances, codes for signs, symptoms, or unspecified codes are the best choice to describe the health care encounter. Code each health care encounter to the level of certainty known for that encounter.

If a definitive diagnosis hasn’t been established by the end of the encounter, report codes for either signs or symptoms, or both, instead of a definitive diagnosis. When enough clinical information isn’t known or available about a particular health condition to assign a more specific code, it’s acceptable to report the appropriate unspecified code.

For example, you can assign a diagnosis code for unspecified pneumonia if the specific type hasn't been documented. Report unspecified codes when these codes most accurately describe what's known about the patient's condition at the time of that particular encounter.