In nearly every ICD-10-CM category there is an option for an “other specified” condition. What do these mean, and how are they properly used?
The official guidelines for ICD-10-CM can help explain. They define the conventions used in the code set. In section 1.A.6.b, the following clarification is provided about a common abbreviation in the tabular list:
NEC (not elsewhere classifiable)
This abbreviation in the tabular list represents “other specified.” When a specific code is not available for a condition, the tabular list includes an NEC entry under a code to identify it as the “other specified” code.
Section 1.A.9.a gives even more guidance:
Codes titled “other” or “other specified” are for use when the information in the medical record provides detail for which a specific code does not exist. Alphabetic index entries with NEC in the line designate “other” codes in the tabular list. These alphabetic index entries represent specific disease entities for which no specific code exists, so the term is included within an “other” code.
Note that, for those categories for which an unspecified code is not provided, the “other specified” code may represent both “other” and “unspecified.”
Consider the following example:
M50.81 Other cervical disc disorders, high cervical region
This code would be appropriate if the documentation suggests some sort of disc disorder, but the other options in the code set do not match. The other choices include disc disorder with myelopathy or radiculopathy, disc displacement, disc degeneration, and unspecified disc disorders. If the patient has one of these other conditions, then these other codes should be considered. But if the disc problem is specifically documented as something other than those choices, M50.81 would be the best option.
Consider another common spinal condition known as facet syndrome. The facet joints are a pair of joints in the posterior aspect of the spine, more properly called the zygapophysial joints. While some differing definitions are available, the most common one cited for facet syndrome is that these joints have become inflamed due to trauma or overuse, thus causing back pain.
Unfortunately, there was no ICD-9 code for this acute condition. However, diagnosis coding guidelines (in ICD-9 and ICD-10) indicate that codes with “other,” “other specified,” or “not elsewhere classified” in the description are for conditions that are not described elsewhere in the code set. In ICD-9 this led coders to use 724.8, Other symptoms referable to the back. While this code noted nothing about facets, it was still the most correct choice by virtue of the word “other.”
Unfortunately, the general equivalency mapping (GEM) translating to ICD-10 for this code is M54.08, Panniculitis affecting region of neck and back, sacrococcygeal region. This is defined as inflammation of subcutaneous adipose tissue, which is not consistent with facet syndrome. Furthermore, this code identifies a specific region, whereas the ICD-9 code did not. This is a great example of how doctors who rely only on GEMs often will end up with the wrong code. Note that if the patient really has panniculitis in the sacrococcygeal region, then this code is perfect.
Unfortunately, there is still no ICD-10 code for facet syndrome. But M53.8-, other specified dorsopathies, can be used just like the old ICD-9 code. This subcategory applies to dorsopathies, which is just a fancy way to say “back problems.” It is the “other” code, which means it can be used for a specified condition, including facet syndrome. The fifth character can be used to designate the specific spinal region.
Another option is the M47- category, because it includes “degeneration of facet joints.” However, a patient may have an acute case of facet syndrome that may not yet include degeneration, which takes time to develop. Therefore, this category may be more properly reserved for more advanced or chronic cases, but it would be inappropriate if degeneration is not yet present.
One word of caution: frequent use of “NEC” or “other” codes could trigger a medical record review. Other, more specific ICD-10-CM codes often can tell the whole patient story correctly on the claim form. These “other” codes may be seen as an invitation to auditors to review the documentation to find out why the provider was unable to find a more specific code.
Of course, providers who document thoroughly and understand ICD-10-CM coding guidelines should have nothing to worry about.