Question

Which coding convention is used in the description of an ICD-10-CM code when the information in the medical record provides detail, but no specific code exists?

Answer 1

In the ICD-10-CM coding convention, when there is no specific code available for a detailed description, coders use 'code not otherwise specified' (NOS) or 'code not elsewhere classified' (NEC) codes.

Step-by-step explanation:

In the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), when there is no specific code available for a detailed description in the medical record, coders are instructed to use a 'code not otherwise specified' (NOS) or 'code not elsewhere classified' (NEC) code. These codes are used to indicate that the information in the record does not perfectly match any existing code, but still provides enough detail for appropriate classification. For example, if a patient's medical record indicates a type of viral infection, but there is no specific code for that particular virus, a NOS or NEC code can be used to classify the infection.