ICD-10-CM for Bilateral Conditions

September 10, 2015


I noticed that the ICD-10 codes for many conditions are specific for right and left. I also noticed that some conditions have a specific code for bilateral. But what if the patient has bilateral disease but there is not a diagnosis code for bilateral? Should I use an unspecified code?


Good question! No, don’t use an unspecified code. The laterality is specified in your documentation, so an unspecified code is inaccurate. If a bilateral code exists and the disorder is documented as bilateral, then the bilateral diagnosis code should be used. But if the documentation states the condition is bilateral, and there is not a bilateral diagnosis code, then use both the right and left codes.

Watch for Kim Pollock’s upcoming webinars on ICD-10 coding for plastic surgery and breast procedures…more information shortly!

*This response is based on the best information available as of 09/10/15.

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