Many practices include only unspecified International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes on their encounter forms and never or infrequently code to the highest level of specificity as documented in the medical record.

The 3-digit codes describe a category of code (eg, suppurative and unspecified otitis media) that may be subdivided into fourth- and fifth-digit codes to allow more specific and detailed reporting. Although the majority of ICD-9-CM codes require a fourth or fifth digit, there are some 3-digit codes. For example, the 3-digit code 486 is used to report pneumonia, organism unspecified. However, fourth- and fifth-digit codes are required when the diagnosis is more specific. For example, if bacterial pneumonia is documented, the appropriate fourth- or fifth-digit code would be reported (eg, 482.2, pneumonia due to Haemophilus influenzae; 482.30, pneumonia due to group A streptococcus). A listing of valid 3-digit codes is provided...

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