Final answer:
When reporting a surgical procedure code that is not specified as bilateral or unilateral, refer to the relevant coding guidelines to determine if a separate code is needed for each side. A unilateral code covers one or both sides, while a bilateral code, with a modifier if necessary, is used for procedures performed on both sides where the code does not specify. Accurate documentation by the surgical team supports correct coding, although procedural coding itself is handled by specialist coders.
Step-by-step explanation:
If a surgical procedure is not explicitly identified as bilateral or unilateral in its description, the healthcare provider or coder must refer to the coding guidelines specific to the procedure coding system being used, such as Current Procedural Terminology (CPT) or the International Classification of Diseases (ICD). Official coding guidelines, the procedure's global package, insurer's policies, or the clinical context of the surgery will determine whether a separate procedure code must be reported for each side, or if a single code covers both sides. It is important to note that a unilateral code is reported once regardless of whether the procedure was performed on one side or on both sides. In contrast, for procedures inherently bilateral or when performed bilaterally and the code description does not specify unilateral or bilateral, the bilateral modifier must be appended if allowed by the payer.
A nurse reviewing items aloud with the team as part of a surgical safety checklist may mention the name of the procedure as recorded, but this role does not usually involve the reporting of procedure codes, which is typically carried out by coding specialists. However, the accurate documentation by the surgical team, including the name of the procedure, can aid in correct coding later on. A detailed review by the staff that includes whether the needle, sponge, and instrument counts are complete, or confirmation that a specimen (if any) is correctly labeled with the patient's name, adds to the safety and correctness of the surgical process but is not directly related to the procedure coding itself.