![]() ![]() ![]() Codes for “unspecified” side should rarely be used, such as when the documentation in the record is insufficient to determine the affected side and it is not possible to obtain clarification. If there is conflicting medical record documentation regarding the affected side, the patient’s attending provider should be queried for clarification. When laterality is not documented by the patient’s provider, code assignment for the affected side may be based on medical record documentation from other clinicians. If the treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate. The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition in the previously treated site. For the second encounter for treatment after one side has previously been treated and the condition no longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists (e.g., cataract surgery performed on each eye in separate encounters). When a patient has a bilateral condition and each side is treated during separate encounters, assign the "bilateral" code (as the condition still exists on both sides), including for the encounter to treat the first side. If the side is not identified in the medical record, assign the code for the unspecified side. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. Laterality - Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. Conventions, general coding guidelines and chapter specific guidelinesġ3. Here is a relevant excerpt from the Official Guidelines for Coding and Reporting: Do not code related signs and symptoms as additional diagnoses.” If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provide whether the abnormal finding should be added.”Īdvice from AHA Coding Clinic 1 st Quarter, 2017 Outpatient Laboratory, Pathology and Radiology coding states, “For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, it is appropriate to code any confirmed or definitive diagnosis documented in the interpretation. The same Coding Clinic also stated, “In the inpatient setting, abnormal findings are not coded and reported unless the provider indicates their clinical significance. The question included examples regarding documentation of a sprain that the radiology report states is a fracture, and about site specificity, when the radiology report is more specific than the documentation in the medical record.Ĭoding Clinic answered the questions by stating that, “If the x-ray report provides additional information regarding the site for a condition that the provider has already diagnosed, it would be appropriate to assign a code to identify the specificity that is documented in the x-ray report.” Will the same advice be true in ICD-10-CM?Ī: The AHA Coding Clinic 1 st Quarter, 2013 answered this question by stating that the same advice would apply to more specific coding in ICD-10-CM.Ī question sent to Coding Clinic asked about the specificity obtained from a radiology report and how it would be coded in ICD-10-CM. Is this still valid for ICD-10-CM?Ĭan you also address if the following advice still applies: An outpatient encounter for pain with no site mentioned and an x-ray is done, and we are instructed to code pain of that site of the x-ray. ![]() Previous advice stated that we can code the fracture. For example, a patient is diagnosed with ankle sprain but when radiology reads the x-ray it shows a fracture. Q: Please advise on the coding guidelines in ICD-10-CM regarding the coding of fractures and their specificity obtained from a radiology report. ![]()
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