by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
September 17th, 2015
Specifying anatomical location and laterality required by ICD-10 is easier than you think. This detail reflects how physicians and clinicians communicate and to what they pay attention - it is a matter of ensuring the information is captured in your documentation. In ICD-10-CM, there are three main categories of changes:
Increased Specificity Over 1/3 of the expansion of ICD-10 codes is due to the addition of laterality (left, right, bilateral).
Physicians and other clinicians likely already note the side when evaluating the clinically pertinent anatomical site(s).