Question

In ICD-10-CM, the final character of the code indicates laterality. An unspecified side code is also provided should the site not be identified in the medical record. If no bilateral code is provided and the condition is bilateral, the ICD-10-CM Official Coding Guidelines direct the coder to

A) query the physician.
B) not assign a code.
C) assign the unspecified side code.
D) assign separate codes for both left and right side

Answer 1

If no bilateral ICD-10-CM code exists for a bilateral condition, coders are directed to assign separate codes for both the left and right sides. ICD codes also appear on laboratory reports and insurance claim forms.

Step-by-step explanation:

When coding in the ICD-10-CM system, if there is no bilateral code provided and the condition is bilateral, the ICD-10-CM Official Coding Guidelines direct coders to assign separate codes for both left and right side. This ensures that the medical record accurately reflects the condition's presence on both sides of the body when a specific bilateral code is not available. Additionally, the guidelines suggest an unspecified side code may be assigned when the affected side is not stated.

ICD codes are used across the healthcare industry for a variety of purposes, such as by clinicians to order the appropriate laboratory tests or prescribe treatments, medical laboratories to identify required tests, health-care management systems to validate treatments, medical coders to assign correct codes for procedures, medical billers to process insurance claims, vital-records keepers to record cause of death on death certificates, and epidemiologists to gather morbidity and mortality statistics.

Two locations where one would likely find an ICD code include medical laboratory reports and health insurance claim forms.