T21.4

Clinical notes

Documentation support

General coding-documentation guidance — not a substitute for payer-specific requirements or professional coding judgment.

• •This is a non-billable header code. Documentation must support a more specific child code before this diagnosis can be reported on a claim.
• •This code describes an unspecified presentation. If the medical record documents a more specific detail (e.g. laterality, type, or affected site), a more specific sibling code should be used instead — see Related codes below.
• •This code represents a manifestation. Documentation should identify the underlying condition, which must be coded first.
• •If the associated manifestation or related condition noted above is also documented, an additional code should be reported alongside this one.
• •As a general rule, code to the highest level of specificity supported by the documentation in the medical record.