General coding standards
Specificity
Always code to the highest level of detail the clinical record supports.
What this means in practice
- Unspecified codes are a last resort. Where the record documents laterality, stage, acuity or organism, the specific code must be used.
- Diagnostic imaging, pathology and other test reports may be used to add specificity to a diagnosis the physician has already documented.
- The explorer flags unspecified codes so a coder can see immediately when a more specific alternative exists in the same category.
Where the explorer applies it
neoplasminflammatorytraumadegenerative
Source and licensing.
Summaries below are original text written for this product and point to the named CIHI standard; they are not a reproduction of it. CIHI content may be reproduced unaltered for non-commercial purposes with attribution - commercial reproduction requires CIHI's prior written authorization.
Canadian Institute for Health Information. Canadian Coding Standards for Version 2022 ICD-10-CA and CCI. Ottawa, ON: CIHI; 2022. CIHI codes and classifications
Canadian Institute for Health Information. Canadian Coding Standards for Version 2022 ICD-10-CA and CCI. Ottawa, ON: CIHI; 2022. CIHI codes and classifications