Cracking the Code
Correctly Reporting Laterality
It is important for medical coders to code diagnoses to the highest level of specificity. This guidance also pertains to laterality diagnosis codes. Per ICD-10-CM Official Guidelines for Coding and Reporting FY 2022, medical coders are instructed to assign separate codes for both the left and right side when the condition is bilateral but there is not a bilateral code available. If the side is not identified in the medical record, then coders should assign the code for the unspecified side. New updated guidance for FY 2022 states that it is appropriate for coders to base the laterality diagnosis code on medical documentation from other clinicians if the patient’s provider is missing this information. When coders are presented with conflicting medical record documentation, they should query the attending provider for clarification.
Q: A 16-year-old male with history of IBS and GERD presents to the ED with abdominal pain. The patient states he has been in pain for the past three days. The attending provider Dr. Ramirez orders an abdominal x-ray, which is completed by Dr. Bennett. The x-ray returns negative with no confirmed cause of the pain. Final impression is left lower quadrant abdominal pain. Dr. Ramirez’s documents the final diagnosis as right lower quadrant abdominal pain.
A: query the attending provider for laterality clarification
Reference: ICD-10-CM Official Guidelines for Coding and Reporting FY 2022 Section I.B.13