E/M Coding Alert - 2017 Issue 7
Reader Question: Assign Laterality When Known
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Article Overview
This reader Q&A discusses ICD-10-CM diagnosis coding for body-site conditions when laterality is documented, not documented, or bilateral. It is relevant to emergency department coders, CDI staff, and billers who need to match the code to the documented anatomic site while following official ICD-10-CM guidance.
Why This Topic Matters
Accurate laterality reporting affects diagnosis specificity and code selection, especially when the medical record does or does not identify the affected side. The article also highlights how official ICD-10-CM guidance addresses bilateral conditions and unspecified side reporting.
What You Will Learn
- How laterality affects diagnosis code specificity
- When unspecified anatomic-site coding is discussed in relation to incomplete documentation
- How bilateral conditions are addressed in general ICD-10-CM guidance
- Why chart review and documentation clarification matter for site-specific coding
Who Should Read This
- Emergency department coders
- ICD-10-CM coders
- Clinical documentation improvement staff
- Medical billers
- Coding educators
Codes Discussed
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