Unspecified infectious disease

This code represents an infectious process where the specific pathogen, site of infection, or clinical syndrome cannot be determined from the available medical record documentation. It indicates the presence of an infection without further diagnostic specificity.

Use this code when documentation clearly states an infection is present, but no further details (e.g., bacterial, viral, fungal, specific organism, or affected body system) are provided. This is typically a last resort when more specific codes cannot be assigned due to insufficient information.

• Avoid using this code if any more specific infectious disease code can be identified from the documentation.
• Query the provider for more specific information regarding the type, site, or organism of the infection whenever possible.
• This code should rarely be a primary diagnosis and often indicates a need for improved documentation.